SERVICE AGREEMENT TYPE *

Clients hiring for Placenta Encapsulation only: I will pick up your placenta as soon as possible after birth, process it in my home over 2 consecutive days and have the product completed within 24-48 hours. ($300)

Doula Clients: I will leave your birthplace with the placenta, process it in my home over 2 consecutive days and have the product completed within 24-48 hours. ($250)

I AM REQUESTING THE FOLLOWING SERVICES *

Placenta Encapsulation (Traditional Chinese Method)

Placenta Print (free, you provide the canvas)

Cord Keepsake (Free)

Name *

First Name

Last Name

Estimated Due Date *

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Phone *

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Partner's Name *

First Name

Last Name

Partner Phone *

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CLIENT RESPONSIBILITY *

Checking each box confirms that you have read your responsibilities and agree to the terms of this contract.

It is my responsibility to arrange for someone (doula, birth partner, friend, family member) to contact Sacred Birth Services following the birth of my baby so that she may come and pick up my placenta.

It is my responsibility to discuss release of my placenta with my provider prenatally and to sign release forms ahead of time.

I am responsible for the safe handling of my placenta. It is my responsibility to ensure proper storage of my placenta in a refrigerator or cooler with the placenta placed on ice until it can be picked up or delivered to Sacred Birth Services for preparation and encapsulation. Failure to do so may result in delayed placenta preparation and encapsulation and may cause decreased potency of nutrients, hormones, and other beneficial attributes of the placenta, and even spoilage of the placenta, which would render it unusable for encapsulation.

I allow Sacred Birth Services LLC to take my placenta from the place that I am birthing my baby for the sole purpose of herbally preparing it.

I understand that no guarantee of results is either offered or implied. I understand that my encapsulator (or their training organization) are not medical professionals and do not diagnose or treat illness.

I understand that general guidelines for dosages are provided for reference only and I trust in my own ability to follow my body for actual dosage decisions.

I release my encapsulator and their training organization from any and all liability resulting from the consumption of my placenta.

I DO NOT have any blood-borne illness or health issues that are transmitted through bodily fluid such as HIV, hepatitis, STD’s, etc.

I understand that if I should develop an infection during labor my placenta will no be viable for encapsulation and will notify my encapsulator