Placenta Service Agreement Birth Giver's & Partner's Name: * Name and Pronoun you go by First Name Last Name Phone * (###) ### #### Email * How find you find us? * Word of Mouth Social Media Recommended by Birth Professionals Other Baby's Due Date: * MM DD YYYY Will this be your first birth? * Yes No Location of Birth * Provider: * Contact to obtain Placenta: * Homer Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Would you like to be notified about upcoming infant massage classes? Yes No Do you have any infectious diseases or sexually transmitted diseases? (for example, HIV/AIDS, Hepatitis, Herpes, Lyme, etc.) If yes please list.: * Do you have any health complications? Are you taking any medication? * Please write N/A, or list any you may have. Select location for services: Outside your home with pickup/drop off ($200): Placenta preparation occurs outside your home. Your placenta specialist will collect and deliver your placenta. Outside your home for locations more than 10 miles outside of downtown Olympia with ❏ pickup/drop off ($220-240): Placenta preparation occurs outside your home. Your placenta specialist will collect and deliver your placenta. Outside your home with self-drop off/pickup ($180): Placenta preparation occurs outside your home. You will be responsible for dropping off and picking up your placenta from your placenta specialist. A photo of your placenta is taken for my records. Would you like a copy of it emailed to you? * Yes No Photo Release * I take photos of your placenta for record-keeping purposes. With your permission, I may use these photos for marketing, advertising, education, peer review, or promotional purposes in print or online. Identifying information will not be shared under any circumstances. Do you give permission for photos of your placenta to be used as described here? Yes, you may use the photos No, do not use the photos. A Free cord keepsake is included in your package This is optional. Would you like a cord keepsake? * Heart Circle Spiral No Are you interested in any of the following placenta add-ons? Tincture $60 Homeopathic 1c and 6c Remedy $80 A $30 DISCOUNT will apply if you choose the following 3 options: Encapsulation, Tincture, and Homeopathic Remedies are $310 instead of $340 Placenta Print on a canvas $20 Placenta Print food coloring $25 Placenta Salve 0,5 oz $15 If choosing a Placenta Tincture, or Homeopathic Remedy; Would you like to get the tissue I used for the Tincture and/or Homeopathic Remedy to plant a special tree for your child? Yes No Are you intersted in the following organic herbal products? All herbal products are handcrafted, mostly grown, harvested, and processed by Diksha from BBI. Nipple Salve 2oz, $15 Diaper Salve 2oz, $15 Cramp Bark Tincture for Afterpains2oz, $15 Cramp Bark Tincture for Afterpains 4 oz, $25 Herbal Sitz-Bath Blend for postpartum recovery, $10 each (makes 2 sitz baths, 2 bags recomendet) Agreement Payment, Cancellation, & Refund Policy ● Payment in full is due latest by the delivery of the capsules. ● You may cancel this contract at any time, but the $60 retainer is non-refundable and covers time spent prenatally and holding aside your space on my calendar. ● If you cancel after the encapsulation process has begun, the balance is due in full, and no refund will be given, even if you choose not to take delivery of the finished capsules. Client Responsibilities ● Talk to your care provider during a prenatal visit about your intended birth place’s policies in regard to releasing the placenta. Sign any forms required and have them placed in your file. ● If you are birthing in a hospital, remind your care providers upon arrival that you plan to take your placenta, and remind them again when you start pushing. ● Put your placenta best into a covered container. The container must be labeled with your name before I pick it up. ● It can remain at room temperature for up to 3 hours following the birth. Refrigerate or put it on ice in a 6-pack-sized cooler as soon as reasonably possible. Improperly handled placentas are susceptible to spoilage. ● Do not let the placenta out of your sight. I cannot encapsulate placentas that are examined in a hospital's pathology lab. ●The placenta still can be processed and ingested with meconium present, you are GBS positive, or there is a marginal cord insertion! ●The placenta can NOT be ingested if there is a uterine infection Chorioamnionitis (which can be present if the birth giver and the baby have a fever!) After the birth, arrange a time to pick up the placenta Call my cell phone at 360-259-6593, leave a message if I don't pick up. If I don't call back within 2 hours, I didn't get your message.. Please call again! I can be reached between 8am to 8pm, the sooner after your birth, as better. Please email or text after 8pm until 8am. PLEASE DO NOT CALL ME IN THE MIDDLE OF THE NIGHT! ● Encapsulation and delivery take 1-2 days for a refrigerated placenta. A frozen placenta will take an additional 1-2 days so that it can be safely thawed. Turnaround Guarantee I will do my best to have your placenta back to you as quickly as it can be prepared safely. This is usually the day after I pick it up, and sometimes the day following. Clients who sign this contract before labor begins receive a turnaround time guarantee. I may choose to have a backup encapsulator process your placenta if I should attend a long birth at the time, so I can meet the turnaround deadline. Clients who contact me for encapsulation after labor begins will receive second priority to contracted clients and do not receive a turnaround guarantee, although I will still strive to return your capsules within 2 days. Limitations and Disclaimer ● I understand and acknowledge that choosing to encapsulate my placenta is not intended to prevent or treat any physical or mental diseases, ailments, or symptoms, and that I am choosing to consume my placenta for my own personal belief, whether it be spiritual or cultural. I also acknowledge that there are no statewide regulations preventing me from obtaining and encapsulating my placenta. ● I acknowledge that Diksha Berebitsky has provided me with concrete information about both the benefits and risks of placenta encapsulation and have read all the included documents. I understand that my placenta will be handled and encapsulated according to OSHA bloodborne pathogens universal precautions and Thurston County Food Safety and Handling standards, and will be cleaned, cooked, dehydrated, and put into pill form in a sanitary and disinfected workspace. Upon receiving my placenta capsules from Diksha Berebitsky, I waive any and all rights to hold either of them responsible for any undesired effects of consuming the capsules. ● I put full trust and acknowledgment that my placenta is being handled in a sanitary and safe environment. I have disclosed to Diksha Berebitsky my STD status. I understand that upon receiving the pills, Diksha Berebitsky is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules. ● I do not hold Blissful Birth Initiations or Diksha Berebitsky responsible or liable for any transport mishap (for example, car accident or detainment). Ingesting your Placenta is a practice dating back thousands of years. However, it is not currently recognized by the FDA; the services discussed are not medical, clinical, or pharmaceutical, nor intended to identify, diagnose, or treat any condition. Families/birth givers who choose to utilize encapsulated or other placenta remedies do so only after doing their own research and taking full responsibility for any and all outcomes. Fees: I agree to the preceding Client Responsibilities, Limitations and Disclaimer, and Refund Policy by signing below: Just type your first and last name along with the date. Thank you!
