Contact information
This form includes: contact information, why you would like your placenta encapsulated, what services you are looking for, estimated due date, what medical practice you are using, provider, liability, refund policy, privacy policy, and choice of payment option.
Email *
Name *
Additional Contact *
(Such as spouse, partner, or other family member who will be at the birth)
Phone number *
Additional Contact Phone # *
(In case you are unreachable)
Address *
Needed for pick up or drop off.
Why do you want your placenta processed?
What services are you looking for? *
(Multiple services may depend on time of birth, and health of placenta, and size of cord.)
Required
What is your Due Date *
MM
/
DD
/
YYYY
Do you have any health conditions? *
What medical facility will you be using?
Who will be your medical provider?
Privacy Policy *
Do you agree to allow your Placenta Specialist to save information such as: contact info., photos for learning purposes, medical history. Information will not be used for social media or other purposes unless requested by the Placenta Specialist who will have a written consent form.
Liability *
I understand that ingesting placenta is not taking place of any prescriptions or other medical remedies. I understand that ingesting placenta might cause side effects such as: anxiety, sleeplessness, hormonal shifts or an oversupply in milk. I agree to notify my Specialist if any side effects occur. I waive all right to holding my specialist responsible for any undesired effects from consuming my placenta. I agree to allow my placenta specialist to process placenta in her home. I agree to notify my Specialist if any STD's or blood born diseases arise. I agree to not hold my Specialist responsible for any transportation mishaps (ex. car crash, or weather, etc.). If you agree and understand all please note "I AGREE AND UNDERSTAND" in the box below.
Payment *
I’m Payment is required upon picking up the placenta before any process has begun. If you would like to set up a different payment option or split the payment please select OTHER then let your specialist know.
Refunds *
If placenta cannot be encapsulated due to: infection of the placenta, damage including (cross contamination, chemical contamination, there is not enough of placenta, spoiling, or the provider accidently disposed of it) there will be no need for any payment. If you decide not to process the placenta after pickup or are unavailable for 2 days after the process is complete no refund will be given and placenta will be deemed not useable. Please note "I AGREE" in the space below.
Electronic Signature *
Printing your signature below means that you have read, understood the terms, and completed the form above. This also means you agree to be considered for placenta processing services by Carleigh Garcia.
Afterwards
Once you submit the form you will receive a call, email, or other from the Placenta Specialist regarding the process and any further questions. Pricing will be discussed at time of consultation. Thank you for taking the time to complete the form!
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