Placenta Encapsulation

PLACENTA ENCAPSULATION AGREEMENT
DUE DATE*

MonthDayYear
CLIENT'S NAME*

First NameLast Name
CLIENT'S ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
CLIENT'S PHONE NUMBER*

Area CodePhone Number
E-MAIL*
Bloodborne Pathogens at time of birth

NoneHIV/AIDSHepatitisSexually Transmitted DiseasesOther
(If other, please explain)
PLACENTA PREPARATION PREFRENCES

The Raw method of preparation is done without any cooking beforehand. It is said to "pack more of a punch" and can possibly lead to stronger results. For the Traditional Chinese Method, we first steam the placenta with ginger and herbs. The method is said to bring warmth back to the organ and by ingesting it this way, it will balance out your chi by bringing the heat that was lost with the disposal of this organ back to your body.
Which method?

Raw MethodTraditional Chinese Method
Umbilical Cord Options

Please DiscardPlease dehydrate so I can keep it as a keepsake.
1. PARTIES. The Client listed above is hereinafter referred to as the “Client.” Fox Valley Birth and Baby is hereinafter referred to as “Doula.” Doula is in the business of providing certified labor doula services and Client wishes to retain Doula’s services as set forth herein.

2. COVERAGE/PACKAGE INFORMATION. Client is purchasing the following:
TERMS & CONDITIONS
CHOOSE ONE:*
Client agrees to pay the following amount for Placenta Encapsulation services:
TOTAL DUE:
TOTAL DUE:
CLIENT WILL PAY BY:*
IMPORTANT INFORMATION
Please discuss with your providers PRIOR to 36 weeks gestation your wishes to keep your placenta. It is imperative no one disposes of or treats your placenta with any chemicals or we will be unable to process your placenta and any deposit made will be forfeited. Please bring with you to the hospital/birth center, the following: TWO gallon sized ziplock bags with your first and last name and room number written in permanent marker on one of the bags. A large cooler or cooler bag to put the ziplock bags in after your birth. We will not come with one ourselves, you must provide your own. We plan to pick up your placenta within 24 hours after the birth. Please call us shortly after the birth so we can schedule a time for pick up/drop off within 24 hours after the birth.
PLEASE READ AND MARK IN AGREEMENT:

I have informed Fox Valley Birth and Baby of any allergies I may have and do not hold them responsible for any reactions to consumption of these pills.I agree that it is my responsibility to inform my care providers that I will be keeping my placenta, and to avoid taking the placenta toxicology, treating it with any chemicals, or disposing of it.I have inquired about and completed any paperwork necessary for the hospital or birthing center to release my placenta to me after my birth.I agree that I am to inform Fox Valley Birth and Baby either when I go into labor or after the birth of my baby (please allow yourself time for bonding, settling, and healing before contacting us. We in no way want to be a disruption to you and your baby.) I understand I may use any method of communication, including email, or by phone or text.I understand I am to keep the placenta double bagged, with my name clearly printed on top, and placed inside my own cooler or bag and kept on ice or refrigerated (not frozen) until I can arrange delivery or pick up of my placenta.I have read the dosage and storage instructions located on our "Placenta Encapsulation" page of our website and agree to contact Fox Valley Birth and Baby immediately upon experiencing and side effects or ill results.I understand the risks of placenta consumption are the same as dining out in a restaurant where food is prepared for me. Other risks may include: placenta being switched with another placenta that is not mine while at the hospital; placenta contamination with chemicals at the hospital pathology laboratory; and contamination during transport due to improper packaging and storage.I am aware that there are no guarantees of a cure for any disease or ailment.I am aware that I may cancel this service at any time until two weeks before my estimated due date, for any reason. After the on-call period has commenced at 37 weeks gestation, I am aware that I forfeit a $50 USD deposit to Fox Valley Birth and Baby. I understand I am responsible for the entire payment at the time of delivery or pick up of placenta and my placenta will not be processed until fee is paid in full.If difficulties retrieving my placenta occur, or any certain birth scenarios prevent encapsulation, Fox Valley Birth and Baby will refund any money received.I have agreed to pay the above amount via cash or check any time before my birth, or at pick up or drop off.
DISCLAIMER
The information on this page has not been evaluated by the Food and Drug Administration (FDA). The services we offer are not clinical, pharmaceutical, or intended to diagnose or treat any condition. Families who choose to utilize the services on this page take full responsibility for researching and using the remedies. The cost of the service is solely for the processing and delivery of the capsules. I HAVE READ ALL OF THIS AND BY SIGNING MY NAME BELOW, SHOW MY AGREEMENT.
CONTRACT IS BINDING AS OF TODAY'S DATE:*

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CLIENT'S E-SIGNATURE:*

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DOULA'S SIGNATURES:
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