Placenta Encapsulation Contract Sample
Thank you for purchasing placenta encapsulation. We strive to make the process simple and easy. Read the contract below, sign and pay. Then we will get your placenta kit to you.
CLIENT AGREES:
• To talk to their care provider during a prenatal visit about your intended birthplace's policies in regards to releasing the placenta, sign any forms required and have them placed in your file.
• Remind your labor nurse upon arrival and on shift changes that you plan to take your placenta and sign any needed forms.
• Following the birth place your placenta in the two Ziploc gallon sized bags with your name on them and place the placenta on ice in the cooler within three hours of delivery
• Call or text Shawna at (847) 502-0228 between (8am-8pm) after the birth to arrange a time to pick up the placenta or meet someone at your location
• If you are not able to contact us within three days of the birth, please place your placenta in a freezer until you are ready for your encapsulation to begin
• That my placenta does not contain any transmittable diseases such as Hepatitis -B -C or HIV/AIDS, and that my care provider and I have determined that my placenta is healthy and suitable for encapsulation
• To inform Shawna Schuerr if you have any health conditions which may affect the health of your placenta or the health and safety of anyone who may come into contact with your placenta
• To not hold my specialist responsible if my placenta is accidentally damaged due to transportation issues, power outages, or any unforeseen circumstances out of one's control.
• That I am paying for the encapsulation service only, not the pills. Which is not clinical, pharmaceutical or intended to diagnose, or treat any condition.
• That no guarantee is made as to how many pills will be produced from the placenta, since each placenta is unique in size and shape.
TRANSPORTATION and HANDLING:
• Permission is granted for your specialist or her driver to transport your placenta for preparation and delivery of completed capsules. Your placenta will be handled and encapsulated according to OSHA blood-borne pathogens universal precautions and the South Carolina Food Safety and Handling standards.
FEES:
• A $50 non-refundable deposit is due at the signing of the placenta encapsulation contract. This is to ensure your due date is on my calendar. The full payment is due by 37 weeks pregnant. In the event your placenta is unavailable to you (sent to pathology) or if your placenta has been contaminated with a bacterial infection. Pure Life Placenta Services will happily refund fees paid minus the $50 non-refundable deposit. Once the placenta has been picked up no refund will be given.
PHOTOGRAPHY AGREEMENT:
• Photos of your placenta or placenta products may be taken for educational, promotional or record keeping purposes. No identifying information will be shared under any circumstances. If you would like a copy of any photographs taken by your encapsulator please note this request on the form below.
DISCLAIMER:
Pure Life Placenta (Shawna Schuerr) is not a licensed medical or pharmaceutical provider and therefore is not able to diagnose, treat or prescribe for any health condition. Benefits of placenta encapsulation are supported by maternal experiences and have not been evaluated by the Food and Drug Administration. Families who choose to utilize the services offered take full responsibility of their health and determine whether the use of placenta preparation may be of benefit to them. Your placenta encapsulator makes no guarantee as to the capsule efficiency, but does guarantee the highest quality of service.
Always speak to your care provider regarding any questions about your health, safety, and well-being. Placenta services are not meant to be a replacement for medical advice or medical care. While many women have found placenta encapsulation to be a wonderful and amazing gift, you are still encouraged to seek appropriate assistance and medical care when necessary.
By signing this form, you indicate that you have read, reviewed and agree to the proceeding information as well as the following:
I have read, understood, and agree to the above procedures, information and statements of policy. By signing my name, I ____________________________________ give my consent to release my healthy placenta to my specialist for the purposes of encapsulation. I accept the responsibility of gaining possession of the placenta after the birth, handling and immediate cooling/storage of the placenta appropriately prior to the specialist taking possession of it, and notifying the specialist of my birth within 72 hours while the placenta is being appropriately cooled and stored. I authorize the release of my placenta to my specialist and I authorize transportation of my placenta for preparation. I have honestly disclosed my health history and all pertinent health details and preparation preferences on this form.
I understand that upon receiving the completed capsules my specialist is not liable for the usage or effects of the capsules, including but not limited to, any other person(s) ingesting my own placenta capsules. Upon receiving my completed placenta capsules, I waive any and all rights to hold my specialist responsible for any undesired effect or differing benefits of consuming the capsules.
Your placenta specialist will keep this document on file as a record of our agreement. No copies will be released to any third parties and all client information will be kept strictly confidential. The information provided has not been evaluated by the Food and Drug Administration.
This agreement is between Pure Life Placenta services and ___________________________ (client):
Description of Placenta Encapsulation:
Placenta encapsulation is the process of preparing the mother's placenta after the birth by dehydrating powdering and placing it into capsules for the mother to use as she sees fit. This is both for Vaginal births and cesarean births.
Please select if any apply
Hepatitis B
Hepatitis C
HIV
STD
Group B Strep
Herpes
Other __________________________________________
Any medications (besides prenatal vitamins):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Please Initial Below:
______ I understand that no guarantee of results is either offered or implied
______ I understand that my placenta encapsulator is not a medical professional and does not diagnose or treat illness
______ I understand that I am paying for the preparation services only not for the pills.
______ I understand that general guidelines for placenta capsule usage are provided for reference only and I trust in my own ability to follow my body for actual usage decisions
______ I ascertain that I have no blood borne diseases that have not been disclosed in writing to my placenta specialist
______ I release my placenta encapsulator from any and all liability resulting from the consumption of my placenta
______ I don't hold my Placenta Encapsulator responsible if my placenta is accidentally damaged during transportation, or encapsulation process due to any unforeseen circumstances out of one's control.
By initialing, I am agreeing to the 7 statements above.
We, The undersigned have read this contract for post-care services. We accept and agree to the terms and conditions above.
Clients Information:
Name: _______________________________________________
Address: ______________________________________________
City: ___________________ State: _______Zip: ___________
Phone: ________________________________
Email: ________________________________________
Estimated Due Date:________________________________
Place of Birth: ____________________________
Client's Signature: ____________________________________ Date Signed: ________________
Partners Information:
Name: _______________________________________________
Phone: ________________________________
Email: ________________________________________
Partner's Signature: ___________________________________ Date Signed: ________________