Placenta Encapsulation

Placenta Encapsulation

Consent form
Name

First Name Last Name
E-mail

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

- Area Code Phone Number
Place of Birth
Due Date

- Month - Day Year
Today's Dates

- Month - Day Year
Choose Service

Placenta pills (170.00) 2 Keepsakes (included) Tincture (add on for 20.00)
Autorization
I authorize Sherly Lopez owner of Womb Sprout to take my placenta home withing 24 hours of my baby beeing born for encapsulation.

I understand this process and consumption of the placenta has not been scientifically tested or approved on the safety or effectiveness by aby goverment agency, and I am doing this on my own free will. By signing the consent form I wave any further responsability from Womb Sprout or it owner.

With this signed form I also agree to send a 50.00 dollars deposit which secure Sherly's availability during and around my due date.
Refund Policy
- In the event you decide you don't want to do the encapsulation before I pick up the placenta. I will refund any payment made except the deposit which will still pay for my availability for your due date.
- In the event the placenta is not release to you for any reason from the hospital I will refund any payment made except the deposit which will still pay for my availability for your due date.
- In the event you decide you dont want the encapsulation but the placenta is in my posession already but I have not started to work on it yet, I will refund any payments except the deposit and a travel fee.
- In the event you dont want the encapsulation after I have started the process no refunds will be made and full payment is due.
Signature

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Placenta Encapsulation

Autorization

Refund Policy