Fort Wayne Tree Of Life Placenta

Name*

First NameLast Name

E-mail*

Phone Number*

Area CodePhone Number

Partner's Name

First NameLast Name

Partner's Phone Number

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Name of partner, or someone whom can be contacted regarding you or your placenta.*

Intended Birth Place*

Estimated Due Date*

MonthDayYear

Name of Care Provider. *

Is This Your First Birth?*

YesNo

Are You Allergic to Latex?*

YesNo

Any Food or Enviromental Alergies?*

YesNo

If "Yes," Please explain

Any Health Concerns or Medications?*

Any Cultures or Traditions you would like accommodated?

How did you hear about us?

Where Would You Like Your Placenta Prepared?

You have the option to select the preparation location that best works for you and the needs of your family. You may choose to have your placenta encapsulated in the specialist’s work space. In that case, the placenta will be picked up from your birth place on the day your baby is born and the capsules will be returned upon completion. If you choose in-home preparation, the kitchen must be thoroughly cleaned prior to the start of services and someone must be present at all times while the specialist is working. In-home preparation requires two visits to complete and involves the use of chemical sanitization methods.

I Choose to Have My Placneta Prepaired...

In My Own HomeIn Tree Of Life's Designated Kitchen

Basic Package - $200

1 Encapsulated Placenta
1 Umbilical Cord Keepsake (optional)
1 Placenta Print. (optional)

Premium Package - $225

All the Benefits of the Basic Package
Plus 1 Additional Add-On of your choosing

Goddess Package - $260

All the Benefits of the Premium Package
Plus 2 Additional Add-On of your Choosing.

Travel Fee - $20

This is for those delivering or living outside a 30 mile ratius of Fort Wayne, IN.

Which Package are you Purchasing?*

Basic Package - $200Premium Package - $225Goddess Package - $260

If your package includes Add-Ons, please indicate which ones you would like.

Placenta TinctureHigh Quality Canvas PrintHalf and Half Preparation (half raw, half steamed)

Would you like your placenta steamed or raw when it enters the dehydrator?*

SteamedRaw

What capsules would you like?*

GelatinVegan

Would you like pictures of your placenta for your own records?*

YesNo

A free print of your placenta is included in your package. Would you like this optional item?*

YesNo

A free umbilical cord keepsake is included in your package. Would you like this optional item?*

YesNo

Shape of the umbilical cord keepsake may be limited due to size and length of the cord. Do you have any shape or design in mind?

Special Instructions, comments, or questions?

Photograph Release

Fort Wayne Tree of Life Placenta may take photographs of your placenta for record keeping purposes. These photos are available to you at any time. With your permission, Fort Wayne Tree of Life Placenta may use these photos for marketing, advertising, education, peer review or promotional purposes in print or online. Identifying information will not be shared under any circumstances.

Do you give permission for your photographs to be used as described above? *

Yes, I do consent.No, I do not consent.

Payment, Cancellation & Refund Policy

Payment in full is due before or at the time the placenta is picked up.
You may cancel this contract at any time but the $50 retainer is non-refundable and covers time spent prenatally and holding aside your space on Fort Wayne Tree of Life Placenta's calendar.
If you cancel after Fort Wayne Tree of Life Placenta has picked up your placenta but before preparation begins, Fort Wayne Tree of Life will return your placenta to you upon request and no further payment is required.
If you cancel after the encapsulation process has begun no refund will be given even if you choose not to take delivery of the finished capsules.

Payment, Cancellation & Refund Policy

Payment in full is due before or at the time the placenta is picked up.
You may cancel this contract at any time but the $50 retainer is non-refundable and covers time spent prenatally and holding aside your space on Fort Wayne Tree of Life Placenta's calendar.
If you cancel after Fort Wayne Tree of Life Placenta has picked up your placenta (or arrived for in-home preparation) but before preparation begins, Fort Wayne Tree of Life will return your placenta to you upon request and no further payment is required.
If you cancel after the encapsulation process has begun no refund will be given even if you choose not to take delivery of the finished capsules.

Client Responsibilities

Talk to your care provider during a prenatal visit about your intended birth place’s policies in regards to releasing the placenta. Sign any forms required and have them placed in your file. Dupont Hospital will have you sign a release form upon admitance.
If you are birthing in a hospital remind your care providers upon arrival that you plan to take your placenta. You may wish to remind them again during the pushing phase.
Put your placenta into a covered container, secured biohazard bag or double zip bag. The container must be labeled with your name before we pick it up.
It can only remain at room temperature for up to 4 hours following the birth. Refrigerate or put it on ice as soon as reasonably possible. Improperly handled placentas are susceptible to spoilage.
I cannot encapsulate placentas that are examined in a hospital's pathology lab. Talk to your care provider prenatally about your options for if it is necessary to send all or part of your placenta to pathology.
Call me at (260)710-2974 after the birth to arrange a time to pick up the placenta. Please call as soon after birth as possible.
Dupont Hospital, currently, has a 48 hour hold on all placentas, I will pick u as soon as i can after the hold is complete.
If you are not able to contact me within 2 days of the birth, freeze the placenta until you are ready for pickup.
Encapsulation and delivery takes 1-2 days for a refrigerated placenta. A frozen placenta may take additional time so that it can be safely thawed.

Two Day Turnaround Guarantee

Fort Wayne Tree of Life Placenta does its best to have your placenta back to you as quickly as it can safely be prepared. This is usually the day after pick up and sometimes the day following that. Clients who sign this contract before labor begins receive a turnaround time guarantee. If your capsules are delivered on the third day after pickup or later you will receive a discount of $25. I may choose to have a backup encapsulator process your placenta if Fort Wayne Tree of Life Placenta has received more than one placenta at a time so that the turnaround deadline can be met. Clients who contact Fort Wayne Tree of Life Placenta for encapsulation after labor begins will receive second priority to contracted clients and do not receive a turnaround guarantee, although Fort Wayne Tree of Life Placenta will still strive to return your capsules within 2 days.

I agree to the previously stated Client Responsibilities, Limitations and Disclaimer, and Refund Policy, as shown by my signature. *

General Information & Policies

Please Read the following carefully.

~Fort Wayne Tree of Life Placenta Specialists are Trained through Association of Placenta Preparation Arts or APPA. APPA is not to held accountable or liable for the actions of Fort Wayne Tree of Life Placenta or its Specialists.

~Talk to your care provider during a prenatal visit about your intended birth place’s policies in regards to releasing the placenta. Sign any forms required and have them placed in your file. If you are birthing in a hospital: remind your labor nurse upon arrival, and on change of shift if applicable, that you plan to take your placenta. Following the birth, your placenta must be placed in a sealed container or double zip top gallon-sized bags and labeled with your name. You are responsible for ensuring that you have met all the requirements of your birthing facility and completed the appropriate paperwork for release if any. You are responsible for the safe handling and appropriate storage of your placenta prior to pickup by Fort Wayne Tree of Life Placenta.

~Call or text message Fort Wayne Tree of Life Placenta at (260)710-2974 after the birth to arrange a time to pick up the placenta. Please call at any time. If you are not able to contact Fort Wayne Tree of Life Placenta within 3 days of the birth and the placenta has been appropriately refrigerated since the birth, please freeze the placenta until you are ready for pickup. Encapsulation and capsule delivery generally takes 1-2 days for a refrigerated placenta. A frozen placenta will take an additional 1-2 days so that it can be safely thawed.

~Permission is granted for Fort Wayne Tree of Life Placenta to transport your placenta for preparation and delivery of completed capsules. Your placenta will be handled and encapsulated according to OSHA bloodborne pathogens universal precautions and Food Safety and Handling standards. Your placenta will be cleaned, steamed (if indicated above), dehydrated and put into capsule form in the sanitary and disinfected workspace indicated above. Fort Wayne Tree of Life Placenta is not responsible or liable for any issues preventing the provision of the services that are beyond its control (ex. car accident, detainment, placenta sent to Pathology Dept., etc).

~Payment in full is due before pick up of your placenta. You may cancel this contract at any time prior to services being rendered. If you cancel after Fort Wayne Tree of Life Placenta has picked up your placenta but before preparation begins, Fort Wayne tree of Life Placenta will return your placenta to you upon request and a refund will be issued to you minus the non-refundable retainer ($50). If you cancel after the encapsulation process has begun no refund will be given. Payment plans can be arranged in advance, when necessary.

~Fort Wayne Tree of Life Placenta is not a pharmacy, pharmaceutical representative, holistic practitioner, herbalist, homeopath or medical doctor. Benefits of placenta encapsulation are supported by maternal experience and have not been evaluated by the Food and Drug Administration. Placenta Encapsulation or placentophagy is intended solely for ingestion by the mother who has birthed the placenta(s) and not for her family members, friends, or other individuals and is not guaranteed to produce specific results. The services offered are not clinical, pharmaceutical, or intended to diagnose or treat any condition. Families who choose to utilize the services take full responsibility for their own health and for researching and using the offered services. Fort Wayne Tree of Life Placenta makes no guarantee as to capsule efficacy but does guarantee the highest quality of service.

~Always speak to your care provider regarding any questions about your health, safety, and well-being. Placenta services are not meant to be a replacement for medical advice, medical care or medicine. If you experience symptoms of postpartum depression, low milk supply, etc. please call your care provider to discuss your symptoms and how to feel better as well as treat any existing symptoms or potential conditions. While many women have found placenta encapsulation to be a wonderful and amazing gift, you are still encouraged to seek appropriate assistance and medical care when necessary. It is always okay to ask for help.

~I agree that I am paying for the encapsulation service only, which is not clinical, pharmaceutical, or intended to diagnose or treat any condition. No refunds for services will be given. My placenta does not contain any transmittable diseases such as Hepatitis-B, -C or HIV/AIDS. My care provider and I have determined that my placenta is healthy and suitable for encapsulation. The placenta has been handled in a manner appropriate for safe food preparation since the birth.

~I understand that Fort Wayne Tree of Life Placenta views each placenta as a sacred connection between mother and child and will treat it accordingly. I will not hold Fort Wayne Tree of Life Placenta responsible if my placenta is accidentally damaged during the encapsulation process.

~Fort Wayne Tree of Life Placenta does not determine whether my placenta should be consumed and makes no guarantee of my personal results from the capsules. The capsules should not be taken during times of illness, such as the common cold, flu, or mastitis. I understand that taking the capsules in any manner other than as labeled can have undesirable results.

~Fort Wayne Tree of Life Placenta will keep this document on file as a record of our agreement. No copies will be released to any third parties and all client information will be kept strictly confidential. The information provided has not been evaluated by the Food and Drug Administration.

Please sign below to indicate that you have read, reviewed and agree to the preceding information, as well as the following:

I have read, understood, and agreed to the above procedures, information, and statements of policy. By signing my name below, I give my consent to release my healthy placenta to Fort Wayne Tree of Life Placenta for the purposes of encapsulation. I accept the responsibility of gaining possession of the placenta after the birth, handling and immediate cooling/storage of the placenta appropriately prior to Fort Wayne Tree of Life Placenta taking possession of it, and notifying Fort Wayne Tree of Life Placenta of my birth within 72 hours while the placenta is being appropriately cooled and stored. I authorize the release of my placenta to Fort Wayne Tree of Life Placenta and I authorize transportation of my placenta for preparation. I have honestly disclosed my health history and all pertinent health details and preparation preferences on this form. I understand that upon receiving the completed capsules, Fort Wayne Tree of Life Placenta is not liable for the usage or effects of the capsules, including but not limited to any other person(s) ingesting my own placenta capsules. Upon receiving my completed placenta capsules, I waive any and all rights to hold Fort Wayne Tree of Life Placenta responsible for any undesired effect or differing benefits of consuming the capsules.

General Information & Policies

Please Read the following carefully.

~Fort Wayne Tree of Life Placenta Specialists are Trained through Association of Placenta Preparation Arts or APPA. APPA is not to held accountable or liable for the actions of Fort Wayne Tree of Life Placenta or its Specialists.

~Talk to your care provider during a prenatal visit about your intended birth place’s policies in regards to releasing the placenta. Sign any forms required and have them placed in your file. If you are birthing in a hospital: remind your labor nurse upon arrival, and on change of shift if applicable, that you plan to take your placenta. Following the birth, your placenta must be placed in a sealed container or double zip top gallon-sized bags and labeled with your name. You are responsible for ensuring that you have met all the requirements of your birthing facility and completed the appropriate paperwork for release if any. You are responsible for the safe handling and appropriate storage of your placenta prior to pickup by Fort Wayne Tree of Life Placenta.

~Call or text message Fort Wayne Tree of Life Placenta at (260)710-2974 after the birth to arrange a time to pick up the placenta. Please call at any time. If you are not able to contact Fort Wayne Tree of Life Placenta within 3 days of the birth and the placenta has been appropriately refrigerated since the birth, please freeze the placenta until you are ready for pickup. Encapsulation and capsule delivery generally takes 1-2 days for a refrigerated placenta. A frozen placenta will take an additional 1-2 days so that it can be safely thawed.

~Permission is granted for Fort Wayne Tree of Life Placenta to transport your placenta for preparation and delivery of completed capsules. Your placenta will be handled and encapsulated according to OSHA bloodborne pathogens universal precautions and Food Safety and Handling standards. Your placenta will be cleaned, steamed (if indicated above), dehydrated and put into capsule form in the sanitary and disinfected workspace indicated above. Fort Wayne Tree of Life Placenta is not responsible or liable for any issues preventing the provision of the services that are beyond its control (ex. car accident, detainment, placenta sent to Pathology Dept., etc).

~Payment in full is due before pick up of your placenta. You may cancel this contract at any time prior to services being rendered. If you cancel after Fort Wayne Tree of Life Placenta has picked up your placenta (or arrived for in-home preparation) but before preparation begins, Fort Wayne tree of Life Placenta will return your placenta to you upon request and a refund will be issued to you minus the non-refundable deposit ($50). If you cancel after the encapsulation process has begun no refund will be given. Payment plans can be arranged in advance, when necessary.