Placenta/Cord Release and/or Donation Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form must be completed ahead of accepting the placenta and/or Cord. By completing this form you are giving Every Birth Matters consent to keep your placenta for teaching purposes, or

Email *

Name *

Address (in full) *

Contact Number *

Expected Due Date of baby *

YYYY

Place of Delivery (home/hospital name/MLU name) *

Have you spoke to your midwife about wanting to keep your placenta/cord? If not please communicate in your birth wishes that you want to keep/take your placenta/cord home. *

yes

I will include this in my birth wishes/plan

Required

For our own protection, we MUST have an honest answer to the following question. Have you ever tested positive for HIV, Hepatitis B or Hepatitis C? *

I am sending Every Birth Matters *

Full Placenta and Cord

Placenta only

Cord only

1. I consent to donating my placenta after the birth of my baby to Every Birth Matters no matter what condition it is when delivered. 2. I understand that I can change my mind at any point. 3. I understand that Every Birth Matters may also take photos/videos of the placenta for educational use. The placenta will not be linked to me via any means. 4. I understand that I am not responsible for the storage of the placenta. 5. I understand that I am signing for Every Birth Matters to take ownership of the placenta for educational purposes only. *

I understand and agree

This is not applicable to me

I understand then when i submit this form, I will receive a copy as my receipt and Every Birth Matters will contact me directly via email. *

I agree

I understand by ticking I agree that I am consenting to donating my placenta to Every Birth Matters. *

I agree

Required

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of EBM. Report Abuse

Forms