Encapsulation Booking & Contract

Encapsulation Booking & Contract
Placenta encapsulation is the process of possible steaming, dehydrating and encapsulating the powdered placenta into pill form for the parent to decide its use. Tinctures are made from a small amount of dehydrated placenta in alcohol, and to be used how the client sees fit. Placenta prints are created using blood and/or food safe colouring (using a barrier) to ensure placenta may still be used for consumption. Umbilical cord keepsakes are prepared by dehydration; may oray not be done depending on length of cord.

I am a traditional and APPA trained & certified Placenta Arts Specialist, however, I am not a licensed medical professional and I am unable to diagnose, treat or prescribe for any health condition. Services and fees are for the preparation/encapsulation of your placenta, not for the sale of the pills/tinctures. No specific benefits, effects or cures are promised. It is your responsibility to determine whether using placenta preparations may be right for you.

If under any conditions you placenta has been tampered with prior to my dealing with, you must inform me. If your medical team suggests testing your placenta, please ask them to take a small amount, so that you can still receive benefit from your placenta. Please also let your medical team that you do not wish for any chemicals to be placed on your placenta.

It is up to yourself (the client) to inform me as soon as possible after placenta delivery to ensure arrangements of pick/drop off are clear. If birth happens overnight, feel free to text me. I will respond the following day. It is your responsibility to make sure your placenta is labeled properly and if in hospital is stored correctly. Please contact me for further guidelines regarding safe storage.

It is your responsibility to discuss with your midwife/doctor/OB your wish to keep your placenta. If birthing in hospital, please let staff know your intended wishes with you placenta when you've been checked in. The nursing staff should right this on your chart. Once you have your placenta with you, please remember to keep it in a fridge/freezer or on ice until encapsulation time in a sealed, clean container.

You are consenting to me processing/handling your placenta. You have informed me of any conditions that may affect the health of your placenta, or the health and safety of anyone involved with it's preparation.

I reserve the right to refuse services depending on various reasons. I do prepare the placenta in my own home, in a dedicated placenta kitchen which I prepare very carefully and diligently, following all BBP suggestions for increased safety of all involved, including my family and yours.

You understand, that I am a private contractor, if for any reason I cannot fulfill my side of the arrangement, I will contact another service provider on your behalf, or suggest another service provider to you.

If in the unlikely event that I have 2 (or more) clients on the same day, you will be notified at time of contact and may be asked to keep your placenta in the fridge/freezer. Birth is unpredictable so while I may be available for your due time, baby's can't read a calendar ;) In a case of multiple clients birthing on the same day it will be first come, first serve, and I will process in a timely manner. Processing can take 3-5* days depending on services requested. Turnaround time could be longer if the placenta is frozen. *Please note that while I generally can stick to these timelines, things may come up outside of my control. If for any reason I will be delayed I will let you know as soon as I am able.

This is a family owned business. I have 2 daughters trained in the placenta arts. To make our family life run smoothly and to optimize my ability to process in a timely manner, my daughter's may step in. My husband, son or daughter may also be the face you see upon pick up or drop off. All are trained in safe handling.

Non refundable retainer is to be paid within 48 hours of booking service. Remainder is to be paid at time of placenta pick up, prior to my starting service.

You understand that I am interested in placenta research and consent that I may take photos of your placenta for this purpose. Pictures may be used in public format, however, for your privacy names will not be disclosed.

*Our services and information provided have not been evaluated by the FDA/HC/FTC. Placenta Edmonton SuperMomma Doula makes no claims of benefit or medical treatment. Articles posted to our site are intended as educational only. The information on this site and any services provided are not clinical, pharmaceutical, or intended to diagnose, treat, cure, or prevent any condition. Those who choose to utilize these services take full responsibility for their own health.
Initial here to accept understanding and agreement of above mentioned information.*
Enter the message as it's shown*
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Can we text?

YesNo
Email
example@example.com
Address - If outside general service area, a small fee may apply. Pick up/drop off details may need to be discussed prior to booking. Capsules may be shipped back via Xpress post with tracking if you are outside the general service area.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternate pick up location details (discussed with Natasha prior to booking, some midwives live in my vacinity, Spruce Grove/Stony Plain area, and maybe able to hold your placenta until pick up is available, this should be discussed with your midwife)
Name of Partner/Support Person (if there is one) for alternate communication

First NameLast Name
Phone Number

Area CodePhone Number
Have you spoken with Natasha regarding services yet?

Not YetText message- 780-318-9336Email- natlongridge@gmail.com
What method/s of encapsulation would you like to book?*

Steamed $250Non Steamed $250Both Methods $275 (placenta is split in half, you will receive a jar of each method)
Capsule Choice - if no option is selected, Gelatin will be used

Gelatin - no additional feeVegan/Gluten Free + $20 (may not be available for last minute bookings)
Extra Add on Options - only available with placenta encapsulation service

Prints - Colour & Blood - $30 (Prints are done on stretched canvas)Prints - Blood Only - $20 (Prints are done on stretched canvas)2 oz Tincture - $30 (tincture can be used/stored for long term needs)4 oz of Tincture - $50 (tincture can be used/stored for long term needs)Basic Cord Keepsake - Free (Included with encapsulation service if cord is long enough)
Special Requests, Questions
Due Date

MonthDayYear
Date
Intended Place of Birth? If birth center, hospital or hotel which one?*
Who is your care provider (OB, Midwife)? Are they aware you are planning to keep your placenta?*
Are there any conditions, concerns, allergies you would like me to be aware of?
Do you have any other children living in your home? Ages?
Every so often I have businesses that donate promotional products, sometimes there may be children's items. I like to give older siblings a gift whenever I can. They're just as special as the newborn :)
You understand that failure to properly store your placenta prior may mean service refusal. *This would depend on time of birth to time of my receiving it. You will receive proper safe storage instructions. In this rare incidence deposit is non refundable.*

I understand
You understand to ensure services, you will have a non refundable, $50 booking retainer.

*If this is a last minute booking, you already have had baby, the full amount is expected.

*Prior to sending along your deposit please text me your name along with your due date to confirm booking, to 780-318-9336. This way I can confirm I have your form, if I need further information and if I am available during your due time.

Once I recieve text, you should hear from me within 48 hours for a confirmation of receiving your form. We can then go ahead with the retainer. Retaiiner can be sent via EMT to natlongridge@gmail.com
Initial that you have read the above booking information. *
Date Retainer Sent*

MonthDayYear
Date
Once baby has arrived and we have made pick up arrangements, please ensure remainder is paid.

I will not start processing until any remainder is paid in full.

If remainder has not been paid within 24 hours of my receiving of the placenta, I will place your placenta in the freezer and send a reminder. I understand life with a newborn can be chaotic, it's best to get payment out of the way once we have made our pick up arrangements. Please also note that if delayed payment happens, processing will be delayed.

Thank you for your understanding. I look forward to working with you!

Natasha
Please initial that you've double checked your contact information to make sure it's all correct & that you understand full payment must be made prior to my processing your placenta.*
Any delay in payment remainder will cause me to freeze your placenta to ensure it's safe to process, until full payment has been received. If payment remainder is an issue, please let me know. I understand how life can be, especially with a newborn. We can possibly work out a payment plan either prior to birth or immediately thereafter. No judgement.

Thank you so very much for taking the time to fill in our booking form. We greatly appreciate you choosing SuperMomma Doula & Placenta Edmonton for your Placenta Services.

The next few questions are just to get to know you a little more and to help how we work. All voluntarily, will not effect services booked. We're looking to improve our services and would appreciate your insight :)

- Nat
How did you hear of SuperMomma Doula & Placenta Edmonton?
Have you worked with SuperMomma Doula & Placenta Edmonton before? If so, what year?
We all know there is a lack of data and research regarding Placenta Arts. Sporadically I do surveys (anonymous) on how encapsulation/tinctures/remedies have worked for people. Would you be interested in being added to an email list for this sort of research?
Would you be interested in being added to a general email list? This would only be for any new information that comes up regarding postpartum healing, pregnancy, placenta related, etc. This may also include any promotions, contests or business updates.
I am horrible at the whole newsletter thing!! So, you'd never be spammed, I hate spam! Parents have too much to do, we don't need extra garbage in our inboxes! I also do not sell or share email lists, ever. I also hate that and wouldn't want to be a part of that.
Are there any other questions, concerns regarding birth or postpartum that's on your mind?
As a birth worker of 20+ years, I don't mind being a sounding board :)
Once again, thanks so much for trusting SuperMomma Doula & Placenta Edmonton with your placenta. We are honoured to work with you!

If you have any other questions that haven't been addressed yet, feel free to send me a text 780-318-9336 anytime.

In the meantime (between now and baby day), take care of YOU.

Congratulations again!! I look forward to chatting soon :)

- Nat
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