Name

First Name

Last Name

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Estimated due date Or Date of Birth

YYYY

Phone Number

Name of other person(s) that may contact Wonder Women about your placenta

Other person phone number

Planned location of Birth

Please list any food or other allergies

Please list any health complications you may have and any medications you may be taking

Do you have any infectious diseases?

Hepatitis

HIV/AIDS

Lyme Disease

Other

Do you have a Doula?

Yes

If so, please list her name in case I need to coordinate pickup of placenta with her.

Doula Phone Number

Method

Please choose Method of Encapsulation

Traditional Method: Placenta is gently steamed with fresh organic lemon, ginger, and jalepeno and then dehydrated. (Note: Lemon, ginger and jalepeno are discarded after steaming and not added to the finished capsules).

Raw Method: Placenta is dehydrated from a raw state.

Extras

Your $250 package includes your placenta pills and cord keepsake. Below are add ons at additional costs.

Please select desired add ons if any

Placenta Print $40

Placenta Balm $50

Additional 2oz Placenta Tincture $40

None

Responsibilities Of Wonder Women Birth

Be "on call" 2 weeks before EDD until birth. Pick up placenta within 24 hours of being notified of birth. Process placenta according to client's choices. Label and return placenta within 72 hours of pickup. Inform client at time of contract signing of any plan to be away during on call periods, and provide client with backup plan. Provide client with instructions for proper storage and suggested dosage for placenta pills and/or tincture.

Responsibilities of Client

Naval Hospital has a policy that all placenta(s) must be off of hospital grounds within one hour of birth. If you give birth between the hours of 2000-0600, you are responsible for finding a way to get your placenta out of the hospital. I recommend having a friend on call to come and pick the placenta up for you. I could then meet with them and grab the placenta for processing. Client will inform Wonder Women Birth when labor begins, or is suspected, as soon as possible by phone betweem the hours of 0800 2100 or by text/email between 2100-0800. If you give birth between the hours 2000-0600, you must make arrangements for you placenta to leave the hospital. Client will inform Care Provider and Hospital if intentions to keep Placenta prior to labor and obtain any forms necessary for it's release. Client will inform Care Provider again when admitted to hospital or at some point before birth of placenta. Client will place Placenta in clean covered container, biohazard bag, or double ZipLock bags and place in refridgerator or appropriate cooler with ice within 3 hour of birth and until I pick up the Placenta. CLIENTS MST BRING THEIR OWN COOLER TO THE HOSPITAL AND IS RESPONSIBLE FOR ENSURING THE PLACENTA IS PLACED ON ICE OR REFRIDGERATED AS SOON AS POSSIBLE AFTER BIRTH, AND NO MORE THAN 3 HOURS AFTER BIRTH. Clients should not let placenta out of sight, a placenta that is sent to pathology can not be encapsulated.

Please Initial that you have read and understand the above Responsibilities of the Client

Payment, Cancellation and Refund Policy

Full payment is due at the time of contract signing. This secures your spot on my calendar. The contract may be cancelled any time by the client, however the $150 will be retained. If the contract is cancelled after picking up the placenta, full payment is still due. If a medical professional deems your placenta unsafe to encapsulate for any reason, a refund of your deposit will be given. NO REFUNDS ARE GIVEN IF CLIENT FAILS TO PROPERLY STORE THE PLACENTA PRIOR TO PICKUP AND I DETERMINE IT NOT SAFE TO ENCAPSULATE.

I understand and agree to the above information; the preceding Responsibilities of Client; Payment, Cancellation, and Refund Policy; and Release of Liability. I authorize the release of my placenta to Wonder Women Birth.

First Name

Last Name