Client Booking Form Step 1 of 2 50% Name* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Estimated Due Date* MM slash DD slash YYYY Partner or Contact Person* First Last Attending the birthPartner/Contact's Phone*Location of Birth* ie, home, specific hospital, or birth centerAddress of Birth Location* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Name of Midwife or OB/GYN* Place of Preparation* In my home In specialist's workspace See FAQ page from pros and cons of each location.Have you had any of the following during this pregnancy? Please check all that apply even if you have received treatment. If you have a history of the following, check the "Other" box and add to the notes at the bottom of the form* None Group B Strep (GBS+) Hepatitis A/B/C HSV Other STI/STDs (HIV, Gonorrhea, Chlamydia, etc) MRSA HPV Other Infections/Diseases List Any AllergiesChoose Your Placenta Package* Basic Encapsulation Package ($325) includes placenta encapsulation, pick up and delivery if needed, complimentary cord keepsake, and full postpartum guide with storage and usage instructions. Premium Encapsulation Package ($350) includes placenta encapsulation and a placenta tincture, pick up and delivery if needed, complimentary cord keepsake, and full postpartum guide with storage and usage instructions. Gold Standard Encapsulation Package ($375) includes placenta encapsulation, plus your choice of any/all add-ons, pick up and delivery if needed, complimentary cord keepsake, and full postpartum guide with storage and usage instructions. Travel Fee Yes, I need to pay for a travel fee. No, I'm inside the service area. If you are outside Jefferson County or beyond Baptist Floyd or Clark Memorial, there is a $40 fee for the extra travel required.Complimentary Cord Keepsake* Yes, please include a cord keepsake. No, I'm not interested a cord keepsake. This is included in all packages, please specify if you want this service.PaymentBooking DepositBasic PackagePremium PackageGold Star PackageChoose a product.Payment Options* Booking Deposit Basic Package Premium Package Gold Star Package Digital Photo Art (add on) Travel Fee Twin Fee Self-Transport Choose to pay a booking deposit or pay for your package in full. If you choose to only pay the deposit, the balance is due before services are rendered. How Did You Hear About Purely Placenta Arts, LLC?* Google Facebook Baby Fair/Event Referral (personal, healthcare provider, doula, etc.) Please let me know if you were referred by someone so that I may thank them! Any other notes Purely Placenta Arts, LLCPlease read the following general policies carefully and fill out and check the consent boxes where necessary. All service preferences and health information listed on your intake form have been noted. Please sign and date at the end prior to returning your completed form. Purely Placenta Arts, LLC respects your right to privacy and assure you that all information will be held in the strictest confidence.Name First Last Email Placenta Encapsulation DescriptionPlacenta encapsulation is the process of preparing the mother’s placenta after the birth of the baby by steaming, dehydrating, powdering and placing it into capsules for the mother to ingest. OSHA blood-borne pathogen universal safety protocols and proper food handling guidelines are followed closely. The purpose of ingestion of the placenta is to reintroduce beneficial hormones, proteins, and other nutrients to her body following labor and birth to help restore balance and provide an overall feeling of wellness to aid in the transition between pregnancy and the early postpartum period. Clarification of Services and DisclaimerI, Sarah Toma (APPAC), am not a licensed medical professional and I am not able to diagnose, treat, or prescribe for any health condition. Services and fees are for the preparation and encapsulation of your placenta, not for the sale of the pills. No specific benefits or effects are guaranteed. Benefits will vary from person to person. Many of the reported benefits of placenta consumption are supported by ongoing research; however these benefits have not been evaluated or approved by the FDA or any other regulatory organizations. It is your responsibility to determine whether using placenta preparations may be of benefit to you. Consent* I acknowledge and agree to the above clarification and disclaimer statement.Storage GuidelinesWhether birthing at home or in a hospital, please ensure that your placenta is kept fresh. It can remain at room temperature for no longer than 2 hours following the birth. After that, (or sooner if possible) it should be refrigerated or otherwise kept cool. If you are practicing some form of delayed cord cutting, ice packs may be wrapped up with the placenta to prevent spoilage for up to 4 hours postpartum. Placenta encapsulation cannot be done after a traditional lotus birth. It is highly recommended that you place a cooler (a styrofoam cooler is acceptable) along with 2 freezer bags in your trunk by 36 weeks. Hospitals generally provide plastic containers, but for a home birth, double bagging the placenta in freezer bags is preferred.Client Storage ResponsibilityIt is your responsibility to discuss release of your placenta from the hospital or where you give birth and to ensure proper storage of your placenta in a refrigerator (below 40 degrees F) or cooler packed with ice until it can be picked up for preparation and encapsulation. *If you are delivering at Norton Suburban, they have a 24hr hold policy and will keep your placenta in a refrigerator at Labor and Delivery. I recommend that you confirm the refrigerator is kept below 40 degrees F for food safety guidelines.Consent* I acknowledge and agree to the above client responsibility statement.Suitability for Consumption* I understand that Sarah Toma does not determine whether or not my placenta is suitable for consumption; it is your responsibility to discuss this with your care provider.BBP* I understand that I must inform Sarah Toma, APPAC, of any known blood-borne illness or other health issues (such as HIV, hepatitis, etc.). In the interest of safety, I understand that I must request in-home encapsulation. I understand that Sarah Toma will not encapsulate in her workspace in this scenario.Unexpected CircumstancesIt is important to note that there may be circumstances under which your placenta cannot be used. Significant abnormalities of the placenta may necessitate your doctor or midwife sending your placenta to Pathology for further examination. Other conditions, such as signs of infection in the mother or baby during labor or within 12 hours, may mean that consuming your placenta will not be beneficial to you. If in doubt, consult your care provider before proceeding. Please be sure to contact me if you or your baby develops an infection within 12 hours of giving birth. I will discontinue the encapsulation process and you will get a refund of all but the non-refundable $50 deposit. We can also plan for different possible keepsakes, or placenta prints if your doctors will release it. It should not be a problem to claim and keep your placenta after Caesarean surgery. To be prepared, it is recommended that your desire to take your placenta be written on a birth plan, and communicated by yourself, spouse, or doula in the event of an unplanned Caesarean surgery. I always recommend restating that you are keeping your placenta after you deliver. FeesFees include the pick up of the placenta, preparation and encapsulation of the placenta, and other chosen services, written instructions for storage and handling, guidelines for taking your capsules, and delivery of your capsules. An umbilical cord keepsake is also provided whenever possible. A $50 non-refundable retainer fee is due upon signing this contract. Balance payment can be made by check (to Sarah Toma) or via PayPal for an extra 3% fee. The balance is payable before or upon pick-up of your placenta. If cost is an issue, please ask about payment plan options. RefundsIf you choose to terminate this contract after releasing your placenta to me, but before any preparation has begun, I will return your placenta to you for disposal. Your $50 retainer fee is not refunded. There will be no refund and payment will be due in full once preparation has begun, even if you choose not to take the delivery of the finished capsules. If something happens beyond your control that makes the placenta unsuitable for preparing (infection, sent to pathology, etc) then a refund will be given. Final Consent* I have read and agree to the terms of this client agreement.Date* MM slash DD slash YYYY E-Signature* First Last Suffix By typing my full name and date in the form above, I am using this as my electronic signature and agree to the terms of this agreement with Sarah Toma of Purely Placenta Arts, LLC. NameThis field is for validation purposes and should be left unchanged.
