Placenta Preparation Agreement

Placenta Preparation Agreement

(Exciting stuff!)
Client Responsibilities

Placenta encapsulation or tincture services will be provided to you, by Birthsource, LLC (referenced hereafter as Kailyn Browning) at the rate of $250 for encapsulation, or $150 for tincture. Should you choose additional product offerings, encapsulation and tincture production services together will be provided to you by Kailyn Browning at the rate of $275 and/or add-on salve production services will be provided for you by Kailyn Browning at the rate of $35. There will be an additional processing fee if paid via online method. This is due either in full at the time of signing of this contract, or in payment plans of no less than $25 a month, with the full amount due by Client’s 38 week gestation. In the event that you agree to have your placenta sent out for testing or it is sent without your approval, the sum total of the amount paid to Kailyn Browning thus far will be refunded, less a $25 deposit.

Client is responsible for tolls and parking fees incurred by Kailyn Browning in relation to providing his/her placenta transport, pick-up, or delivery.

Client is to make arrangements in advance with the birth facility for release and proper storage of his/her placenta. Contact me if you require assistance or direction with this.

Kailyn Browning is responsible for transporting the placenta from the birth place (or other agreed upon point of transfer) to her home where the placenta processing will take place.

Client will properly package and store the placenta for transport. The placenta can remain at room temperature for three to four hours after birth. The placenta is to be double-bagged in gallon-sized freezer bags and kept cool either in a refrigerator or on ice. If it is not possible for the placenta to be encapsulated within the first 48 hours after birth, keep the double-bagged placenta in the freezer. The placenta is to be defrosted in the refrigerator 24 hours before preparation. Never freeze, thaw, and re-freeze the placenta.

Please notify Kailyn Browning (740) 818-5039 by phone call within 12 hours of the birth to make arrangements for service. The sooner you are able to notify, the better.

Kailyn Browning is responsible for transporting the processed placenta to the client’s home after it is completed, assuming said client's home is within a 60 mile radius.

In the unlikely event of unforeseeable equipment failure resulting in the loss of placenta, the full paid amount will be refunded to Client.

Process

Your encapsulated placenta will take 2-4 consecutive days to prepare. All preparation will take place in Kailyn Browning’s home. You will receive usage information with your encapsulated placenta and Kailyn will answer any questions that you have. There is no guarantee as to how many capsules your placenta will yield. You can expect between 75-250 capsules. The amount of capsules varies as does the size of the placenta.

Limitations & Disclaimer

The benefits of ingesting your placenta have not been evaluated by the Food and Drug Administration. Your encapsulated placenta is intended for ingestion only by the mother that birthed it. There is no guarantee that the ingestion of your placenta capsules will yield the desired result(s). Kailyn Browning is not a licensed medical professional, and cannot make any diagnosis or suggest treatment. The client takes full responsibility for her health and the research and use of her encapsulated placenta.

Please feel free to contact me with any questions or concerns: support@mybirthsource.com or call/text (740) 818-5039
Please initial each box below

I understand that no guarantee of results is either offered or implied *
I understand that Kailyn Browning is not a medical professional and does not diagnose or treat illness
I ascertain that I have no blood-borne diseases that have not been disclosed in writing to Kailyn Browning *
I release Kailyn Browning from any and all liability resulting from the consumption of my placenta *
I understand that general guidelines for placenta capsule, tincture, and salve usage are provided for reference only and I trust in my own ability to follow my body for actual usage directions*
I understand that equipment failure is beyond the control of Kailyn Browning *
I have read, understand, and agree to the terms described in the Placenta Preparation Agreement above. I certify that all information disclosed above is accurate.*

Clear
Client Name*
Date*

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Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Estimated Due Date
Birthing Location/Facility
Birthing Location/Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Select your placenta products!*

Encapsulated Placenta - $250 (pls add $7.00 for fee coverage if paying online)Placenta Tincture without capsules - $100 (pls add $6.00 for fee coverage if paying online)Encapsulated Placenta and Placenta Tincture - $275 (pls add $7.00 for fee coverage if paying online)Placenta Salve Add-on. May be added to tincture and/or encapsulation orders -$35 (please add $3.00 for fee coverage if paying online.)

Make it official!

USDPlease pay full fee for your product choices, or $25 if payment plan agreement has been made. ****If paying with a different method, please put a zero in the dollar amount box in order for form to submit.***

Payment Methods

Credit Card

Apple Pay

Google Pay

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