Estimated Due Date
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Name of Provider
If you have a doula supporting you, what is their name and phone number?
Please tell me why you are choosing to encapsulate your placenta
Nordic Mama Placenta Encapsulation
LIMITATION AND DISCLAIMER
I AM NOT A LICENSED MEDICAL PROFESSIONAL AND I AM NOT ABLE TO DIAGNOSE, TREAT, OR PRESCRIBE FOR ANY HEALTH CONDITION. SERVICES AND FEES ARE FOR THE PREPARATION AND ENCAPSULATION OF YOUR PLACENTA ONLY, NOT FOR THE SALE OF THE PILLS. NO SPECIFIC BENEFITS OR EFFECTS ARE PROMISED AND BENEFITS WILL VARY FROM PERSON TO PERSON. MANY OF THE ASCRIBED BENEFITS ARE WELL SUPPORTED BY RESEARCH, BUT NONE HAVE BEEN EVALUATED BY THE FDA. IT IS YOUR RESPONSIBILITY TO DETERMINE WHETHER PLACENTA PREPARATIONS MAY BE OF BENEFIT TO YOU.
IT IS YOUR RESPONSIBILITY TO NOTIFY ME AS SOON AS POSSIBLE AFTER THE BIRTH TO MAKE ARRANGEMENTS FOR TRANSFER OF YOUR PLACENTA TO ME. FAILURE TO SO MAY RESULT IN DELAYED PLACENTA PREPARATION & ENCAPSULATION, AND CAN CAUSE DECREASED POTENCY OF NUTRIENTS, HORMONES AND OTHER BENEFICIAL ATTRIBUTES OF THE PLACENTA. YOUR PLACENTA MAY BE KEPT AT ROOM TEMPERATURE FOR 3-4 HOURS FOLLOWING YOUR BIRTH. AFTER THAT, OR AS SOON AS POSSIBLE, IT SHOULD BE PLACED ON ICE OR IN A REFRIGERATOR. I COME PICK UP BETWEEN THE HOURS OF 8 AM AND 9 PM. IF YOUR BABY IS BORN OVERNIGHT THE PLACENTA WILL NEED TO BE PLACED ON ICE OR IN A REFRIGERATOR. IF IT IS GOING TO BE 3 OR MORE DAYS BEFORE YOUR PLACENTA CAN BE PROCESSED, IT SHOULD BE FROZEN. A FROZEN PLACENTA MAY REQUIRE 1-2 ADDITIONAL DAYS FOR PROCESSING SINCE IT MUST BE GENTLY DEFROSTED PRIOR TO BEING DEHYDRATED. IMPROPERLY HANDLED PLACENTAS ARE SUSCEPTIBLE TO SPOILAGE AND ALL PLACENTA WORK IS DONE AT YOUR OWN RISK. IT IS YOUR RESPONSIBILITY TO DISCUSS THE RELEASE OF YOUR PLACENTA WITH YOUR PRIMARY HEALTH CARE PROVIDER AS WELL AS THE FACILITY YOU WILL BE BIRTHING IN. PLEASE MAKE SURE YOUR PLACENTA IS REFRIGERATED OR KEPT ON ICE UNTIL IT CAN BE PICKED UP OR DELIVERED FOR PREPARATION AND IF YOU AGREE TYPE 'I AGREE'
Fees and Payment
A $50.00 deposit is due with the submission of this agreement. Prepayment is an option for those that prefer it RefundsIn the event your placenta is unavailable (ie. you receive medical treatment that renders the placenta unusable, or you change your mind prior to releasing your placenta to me) – any fees paid minus the non-refundable deposit will be refunded in full.If you choose to terminate this agreement after releasing your placenta to me, but before placenta preparations have begun, I will return your placenta to you (if you want it) and a fee of $25 will be charged for time and travel.Once preparation of your placenta has begun, there will be no refunds and payment in full will be due, even if you choose not to take delivery of the finished capsules.
By signing you attest that all information provided is true and accurate to the best of your knowledge. Additionally, you agree to all terms and conditions discussed above.
Please choose the service(s) you would like
Full Service Capsules (Raw or TCM), Tincture, Salve, herbal bath, and print - $325
Full Service Capsules (Half and Half), Tincture, Salve, herbal bath, and print - $340
Placenta Encapsulation - $250 for Raw
Placenta Encapsulation - $265 for TCM Methods
Placenta Encapsulation - $280 for Half and Half of each method
Placenta Tincture - $25
Placenta Salve - $25
Placenta Print - $10
Healing Herbal Bath - $15
Twins Placentas Processed Together - additional $50
Twins Placentas Processed Seperately - additional $100
Comments and Questions
PAYMENT - Please only choose deposit unless you are prepaying for services.
( X )
Full Service Raw or TCM
Full Service Half and Half
Raw Prep Capsules Only
TCM Prep Capsules Only
Half and Half Prep Capsules Only
Healing Herbal Bath
Twin Placenta Processed Together
Twin Placenta Processed Seperately
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