Placenta Encapsulation Waiver

Client's Name

First NameLast Name

Client's Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Client's Email

example@example.com

Client's Phone Number

Area CodePhone Number

Secondary Contact

First NameLast Name

Secondary Contact Phone Number

Area CodePhone Number

Relationship to Client

Due Date

Date

Location of Birth

Name of Hospital/Birth Center or HOME

Address for Placenta Pick-up

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I would like my Umbilical Cord dehydrated for a keepsake. FREE

Yes pleaseNo thanks

How would you like me to prepare your placenta? $325

Raw Method: Dehydrated RawTraditional Chinese Method: Steamed with Lemon, Cayenne & Ginger prior to Dehydration

TERMS and CONDITIONS

The following statements refer to Muriel Webster as 'Practitioner'

1. LIMITATIONS AND DISCLAIMER While Placental nutritional supplement benefits are supported by ongoing research, the supplements have not been evaluated by the Food and Drug Administration, and Client is taking full responsibility for taking these supplements; absolving practitioner of all liability. Practitioner will provide information and suggested doses of treatment. Practitioner is self-employed and does not work for any medical facility, birth site, or health care professional. Practitioner does not take the place of any health care provider, and Client understands that she is in charge of her health care. Client commits to consulting her health care provider if unusual symptoms present. Placental supplements are not clinical, pharmaceutical, or intended to diagnose or treat any condition. Women and their families who choose to utilize the services take full responsibility for their health and use these remedies at their own risk.

2. SERVICES NOT PROVIDED: Practitioner will NOT make decisions for Client. Practitioner will help Client get information necessary to make informed decisions. Practitioner is not a medical provider, pharmacist, or holistic practitioner, and all health decisions must be made by Client. Placenta supplements as defined in this contract are for nutritional supplementation only and cannot be guaranteed to produce any specific results. Practitioner cannot take Client’s Placenta from the medical provider without Client’s written permission, and cannot sign any forms to take possession of Client’s Placenta. Client or Client’s Partner will be responsible for speaking to Hospital Staff. Practitioner does not conduct any medical procedures.

3. CLIENT RESPONSIBILITY It is the Client’s responsibility to notify practitioner as soon after the birth as possible to request pick-up of the Placenta(s) by practitioner at the location indicated on this form. Failure to do so may result in delayed placenta preparation and encapsulation and may cause decreased potency of nutrients, hormones, and other beneficial attributes of the Placenta, and even spoilage of the Placenta which would render it unusable for encapsulation. It is the Client’s responsibility to discuss release of her Placenta after her birth from the establishment where she delivers. Client understands she must ensure proper storage of her Placenta in a refrigerator or cooler with the Placenta placed on ice (for up to 72 hours after the birth) until it can be picked up by practitioner for preparation and encapsulation.

4.Client agrees to inform practitioner of any known blood-borne illness(es) or other health issues that practitioner may become infected with through contact of bodily fluids (specifically maternal and fetal blood and amniotic fluid), such as HIV, hepatitis, STD’s, etc.

5. PERMISSION TO TRANSPORT CLIENT’S RAW PLACENTA Client understands that by signing below, Client is giving permission to practitioner to pick up and transport Client’s raw Placenta for the express purpose of preparing the Placenta in accordance with this Contract. Permission to transport Client’s raw Placenta is granted without Client in the vehicle. If so contracted, practitioner agrees to ensure proper handling of the Placenta.

6. RELEASE FROM LIABILITY: In entering a contract for Placenta Services, Client acknowledges that during the performance period of this contract services may be provided to Client in her home, birthing facility, or a medical facility. Client understands that practitioner has a limited role pursuant to the descriptions of tasks outlined in the above-referenced contract, wherever services are provided. Practitioner has not represented to Client that contracting for her services guarantees in any way a risk free result of using the Placental nutritional supplements. Client understands that practitioner does not make medical decisions. Client and Client’s representative (both jointly and separately) on behalf of Client, Client’s representatives, Client’s heirs, administrators, personal representatives, and executors assigns to release and forever discharge practitioner from all damages or causes of action, either law or in equity, which Client has or acquires or which may accrue to Client, Client’s heirs, administrators, personal representatives, executors or assigns as a result of using practitioner, Client intend this to be a complete release and discharge Muriel Webster from all liability whatsoever.

Signature: By signing, you are agreeing with all TERMS and CONDITIONS

Date of Signature

Date

This form is for use by HELD

Harpswell, ME