Placenta Remedies Booking Form

Expected Due Date *

MM

DD

YYYY

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birth Partner's Name *

After you have given birth, your priority is resting and settling in with your brand new baby. It may be more convenient for you if your birth partner liaises with me to coordinate the placenta pickup.

First Name

Last Name

Have you written on your birth plan that you are taking your placenta and discussed this with your midwife/doula/doctor? *

Yes

No, but we will

In the last 6 months, which of these have you been tested for? *

For your own protection, we MUST have honest answers to the following questions. It is a requirement to produce your hospital antenatal card displaying this information.

Hepatitis B

Hepatitis C

HIV/AIDS

Were all tests negative? *

Yes

No

Do you understand the possible risk of consuming your placenta after having smoked during your pregnancy? *

Research is being done on the effects of smoking during pregnancy on the placenta. Until this is completed, we recommend avoiding the consumption of placenta as heavy metal toxins found in cigarette smoke have been found to remain trapped in placental tissue. The overall buildup of these heavy metals may increase to the point that would make it unsafe to consume by the time the baby is born.

N/A - non-smoker

Yes

No

Have you ever suffered from anxiety, depression, excessive 'baby blues' or postnatal depression? *

The ‘baby blues’ are a known symptom of birth and mothers are told to expect to feel sad, anxious and very emotional around the third day after the birth, usually when the milk engorges the breasts. These symptoms can sometimes develop into postnatal depression and mothers with a history of anxiety and depression are considered higher risk of developing PND. Studies have proven that the symptoms of postnatal depression are linked with the severe lack of essential nutrients such as vitamin B6 and hormone CRH (our stress reducer hormone), both which are of high supply in the placenta. Consuming the placenta in raw smoothies or in capsules is believed to replace lost essential nutrients and hormones and may contribute towards prevention of the ‘baby blues’ and postnatal depression. Medications - When prescribed for a pregnant mum, the medication is usually considered safe and usually regular medication is not retained by the placenta in significant enough quantities to be a problem when ingested. However we do advise you to seek the advice of your doctor.

Yes

No

Remedies

Placenta Encapsulation - Raw - $300

Placenta Encapsulation - TCM - $320

Smoothie - $70

Tincture (150ml) - I am purchasing encapsulation - $50

Tincture (150ml) - I am NOT purchasing encapsulation - $100

Natural Skin Care (120ml Lotion, Hand Cream or Soothing Balm) $85

DIY Smoothie Specialist Training - $40

Travel Fee - $35hr

Payment Method *

BANK DETAILS Here are the details to pay via bank transfer: BSB: 242-200 Account number: 430973370 Name: MRS NANCY E MCLEAN

PayPal - http://paypal.me/nancymclean (+ $10 FEE)

Bank Transfer

Terms & Conditions *

1. IPEN Certified Specialists provide placenta services including placenta encapsulation, raw placenta smoothies, tinctures, and cream remedies. 2. IPEN Certified Specialists have been trained and certified by IPEN, The Independent Placenta Encapsulation Network, to provide placenta information and encapsulation support to the public. IPEN does not provide insurance for Placenta Specialists and the Client’s relationship is solely with the Specialist. 4. Placenta encapsulation itself is experimental in nature and, whilst the benefits of consuming the placenta post-birth are based on research studies, articles and testimonials from new mothers, this research is ongoing and IPEN & Nancy McLean do not give any warranty or representation that these benefits are guaranteed. 5. Clients who choose to utilise these services take full responsibility for their own health and for researching and using the remedies provided in this service. 6. The Client agrees that IPEN, IPEN Certified Specialists or Nancy McLean are not liable and do not take responsibility for any results or effects the Client may experience before, during or after consuming the placenta. 7. IPEN recommends placenta capsules are for the Client’s own consumption only. 8. IPEN Certified Specialists will not handle placentas of Clients who have ever tested positive for any blood borne disease (HIV, AIDS, Hepatitis B, Hepatitis C, Creutzfeldt-Jakob disease). 9. All methods of cleaning and disinfection of equipment used by IPEN Certified Specialists are compliant with food safety regulations in Australia. 10. IPEN Certified Specialists take pride in using natural techniques when preparing the placenta, however one chemical disinfectant may be used to disinfect our equipment after each use. 11. Your IPEN Certified Specialist aims to prepare the placenta within 3 days of the birth. However we will not be held accountable should circumstance arise where the placenta encapsulation cannot be completed until an agreed date and time. Please see documents ‘IPEN Placenta Encapsulation Information Guide for Expectant Mothers’ and ‘Appropriate Placenta Care’ guidelines for handling of your placenta. 12. IPEN Placenta Specialists do not take responsibility for damaged or lost placentas before the placenta comes into our care. 13. The Client agrees to store the placenta in a clean, labelled container inside a cooler box/bag on ice or in refrigerator within 1 hour of birth of the placenta and agrees to ensure her placenta remains chilled until collection. IPEN Specialists reserve the right to refuse services based on their own assessment of your placenta upon collection. In order to ensure we deliver a quality and food safe product we must ensure our placenta storage guidelines have been met. To prevent disappointment and refusal of services we advise you follow our placenta storage guidelines and you ensure your placenta is chilled within 30 minutes after birth. If refusal occurs, you will receive a full refund less the deposit and any applicable travel fee. 14. The Client agrees to contact the Placenta Specialist within 3 hours of birth to arrange safe collection of the placenta for transfer. 15. The Client will be liable for damaged property and/or equipment belonging to us should any equipment become broken and/or damaged whilst in the Client’s care. 16. The Client consents to the removal of the placenta from the hospital by the Specialist to the extent necessary for the preparation of placenta remedies by the Specialist. In the event the placenta is not released by the attending doctor/hospital you will receive a full refund less the deposit and any applicable travel fee. 17. Raw preparations are not suitable if meconium was present in amniotic fluid. If this is the case, the placenta is steamed for encapsulation and any prepaid smoothie charge will be refunded. 18. If a uterine/placental infection is present we are unable to offer any placenta remedies. If this occurs, you will receive a full refund less the deposit and any applicable travel fee. 19. The Client agrees to complete a Feedback Form online following the encapsulation and the Client agrees to answer the questions honestly to help provide statistics and testimonials for IPEN and Nancy McLean. 20. $100 of your payment is a considered a non-refundable deposit. Important Dislaimer Please note: Placenta remedies and are not meant to prevent, treat or diagnose any disease, illness or symptoms. Clients understand that they are assuming all risks and benefits based on their own research and belief of the placenta's healing and nutritional properties. By checking the box below you agree that all the information you have given is correct to the best of your knowledge. You also agree to the Terms and Conditions above and that you will thoroughly read and will follow all the guidelines emailed to you in the document entitled ‘IPEN Placenta Encapsulation Information Guide for Expectant Mothers’ ensuring the proper care and safe storage of your placenta.

I agree

I don't agree