Placenta Encapsulation Form

Address

Encapsulation Method*
Raw $275 - Your placenta is cleaned, prepared, dehydrated and then encapsulated.TCM (Traditional Chinese Method) $275 - Your placenta is cleaned, prepared and steamed with nourishing herbs before being dehydrated and then encapsulated.

Collection*

I come to you to collect the placenta. I deliver the encapsulated capsules in person within 72 hours post birth.

Where are you birthing?*
Zone1 $25– King Edward Memorial Hospital, Family Birth Centre, SJOG SubiacoZone 2 $50– Osborne Park Hospital, Glengarry Private Hospital, Fiona Stanley Hospital, Bentley, Attadale Private Hospital, SJOG Mt Lawley, SJOG MurdochZone 3 $70– Joondalup Hospital (Public/Private), SJOG Midland, Armadale Hospital, Swan District HospitalZone 4- $100- Rockingham General Hospital and Peel Health Campus

For a home birth, the transport cost is:
Homebirth within 10km of Subiaco: $25Homebirth within 20km of Subiaco: $50Homebirth within 50km of Subiaco: $70

Would you like a complimentary cord keepsake?*
Yes (Heart Shape)No

Placenta extras (placenta print, cord art, tincture, broth)

Additional to your placenta capsules you can request a placenta print, tincture or broth.

Placenta Print $20 - The print is taken using the fetal side of the placenta and printing onto A3 paper. Placenta prints are produced using the natural raw colour of the placenta, no colour or dyes is added.Placenta Tincture $40 - Placenta tincture is made from the mothers own placenta powder in a prepared solution of high-grade alcohol for a minimum of 6 weeks. Tinctures are very beneficial once the placenta capsules are finished. The tincture is used in any time of emotional distress, transition, hormonal imbalance or illness. Stored in a cool, dark place the tincture will remain shelf-stable for many years.Placenta Broth $10 - In the Traditional Chinese Medicine inspired preparation of placenta encapsulation, the steaming process creates a rich broth loaded with nutrients. The placenta is steamed with chilli (optional), lemon and ginger. The liquid from the steaming process can be added to your favorite tea, juice, smoothies, or used in a soup. This broth is often referred to as Placenta Broth, Mother's Broth, or Miracle Soup. When consumed, this nutrient-dense, tonified broth aides in the healing and recovery of the newly postpartum mother's body.Cord Art $0 (Included in you placenta encapsulation package) - The umbilical cord that connected the baby to the womb during the pregnancy played a key role in delivering nutrients and essential blood to the baby during gestation. To honour and treasure the umbilical cord it can be dehydrated into a love heart shape (depending on the length) and kept for a lifetime. Popularly placed in baby books, frames or memory boxes.

I always return cord clamps too. These are a lovely keepsake and reminder of your babys' birth.

Do you have a support person?*

Yes (see next question)No

Is your OB/Midwife aware of your decision to encapsulate?*

YesNo

Is this a twin pregnancy?*

YesNo

Have you ever tested positive for HIV/AIDS, hepatitis A, B or C or syphilis?

YesNo

Type of birth you're preparing for (for my own records only)*

Scheduled C-SectionVaginal NaturalVaginal Medicated

Do you carry any other bloodborne diseases that you are aware of?*

YesNo

Do you consent to photos being taken of your placenta throughout the process?*

Yes (see next question)No

Terms & Conditions

Please read the Terms and Conditions of the service.

1. Benefits of placenta encapsulation are based on research, although I, Divine Mother,do not guarantee results or benefits, and do not take responsibility for any side effects the client may experience during or after consuming their placenta capsules.

2. Clients take responsibility for their own health and have done their own research as to inform themselves on the benefits and methods of placenta encapsulation.

3. It is the clients responsibility to get her placenta released to her from the birth facility.

4. It is the clients responsibility to follow recommended storage measures to ensure optimal preservation of their product. Client is responsible for providing cooler bag and ice brick.

5. I take pride in the natural process used in encapsulation, however some disinfecting chemicals must be used to ensure a sanitised and hygienic environment.

6. I do not take responsibility for damaged/lost placentas before coming into Divine Mother posession.

7. I only advise for the mother whose placenta is used in the placenta capsules to consume the product. We do not take responsibility for legal/health implication of others consuming.

8. Testing and results of Hepatitis B & C, syphilis and HIV/AIDS must be disclosed at booking.

9. For health reasons, I cannot process the encapsulation of a placenta of a mother who has tested positive to Hepatitis C, Hepatitis B, HIV/AIDS, Syphilis or any bloodborne disease.

11. Client agrees to keep placenta in their sight at all times to ensure it does not go to a lab where it will be contaminated by chemicals or other harmful substances rendering it unsafe for consumption.

12. Client understands that upon receiving placenta pills and products, Divine Mother is no longer liable, including but not limited to any other persons ingesting client's placenta.

13. IMPORTANT: Full payment must be made at the time of booking. This is the easiest way to avoid chasing money up when you have a newborn. Please make payment into account with your full name & due date

Name: Kara Allan
BSB: 036 051
ACC: 522 452

14. Upon your payment, I will reserve your spot on the calender, and will not make other reservations around your estimated due date. Refunds cannot be given, Unless unplanned events occur (only including a miscarriage or early term birth before 26 weeks).

15 .If I am unable to provide placenta services due to illness or am otherwise incapacitated, all efforts will be made to send a back-up specialist. Contract will then be taken over by the back-up specialist. If I am unable to provide services and no back up specialist is available, the placenta can be frozen and encapsulated as soon as possible. If after this the service can still not be carried out, a full refund will be given.