Placenta encapsulation - booking form. Name * First Name Last Name Email * Estimated Due Date MM DD YYYY Expected Place of Birth Address 1 Address 2 City State/Province Zip/Postal Code Country Secondary Contact Person First Name Last Name Secondary Contact Person Phone Number (###) ### #### I am free of transmittable diseases such as HIV, Hep B or Hep C etc. Yes No Do you have other children? If so, have you previously consumed your placenta? Services Raw Method TCM (Traditional Chinese Medicine Method) Half Raw / Half TCM Cord Keepsake Twins - add ($50) Tincture (add $40) Other information Terms & Conditions Client Obligations • It is the responsibility of the client to communicate with Matrescence Australia (Andrea Dickson) when labour commences to ensure collection of the placenta as soon after birth as possible. Please note that if this does not occur it may delay the collection and processing time of the placenta. • The placenta will be provided to Matrescence Australia (Andrea Dickson) either bagged or placed in a clean, suitable container. • The placenta will be stored appropriately until collection time and ready for transport - either having been refrigerated or placed on ice. • If there is a large delay in the collection of the placenta, it is the client's responsibility to ensure the placenta is frozen ready for collection • Release of the placenta from the hospital (if this is the intended place of birth) is also the responsibility of the client to organise. • In the presence of Group Strep B & or Meconium please note this does not make the placenta unsuitable however the TCM is recommended on these occasions. I understand that: • I am not purchasing my own placenta but playing Matrescence Australia (Andrea Dickson) to prepare my baby's placenta and encapsulate it for my own personal use. Placenta Encapsulation is the process of preparing the placenta after the birth of the baby by dehydrating, powdering and placing it into capsules for the mother to ingest. The placenta will be handled in a manner appropriate for safe food preparation from birth. • Matrescence Australia (Andrea Dickson) is not a licenced medical profession and is unable to diagnose, treat or prescribe for any health conditions. • All preparation, decontamination and sterilisation methods comply with Blood Borne Pathogen guidelines and regulations. • No benefits or effects are promised - benefits or effects may vary from client to client. • No placenta's will be processed without prior payment in full prior to the commencement of the on-call period. • A deposit invoice of $100 will be actioned upon acceptance of this request form via email. I understand I would like further explanation about something Thank you!