Client Name
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First Name
Last Name
Phone
*
(###)
###
####
Mailing Address
*
*Please notify me if your address will change before your estimated due date. Please also double check for accuracy.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Estimated Due Date
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MM
DD
YYYY
Name of Partner or Contact Person
First Name
Last Name
Contact Person's Phone
(###)
###
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Planned location of birth
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Center for Birth - Seattle (+$25 travel fee)
Eastside Birth Center - Bellevue (+$30 travel fee)
Evergreen Health - Kirkland (+$35 travel fee)
Federal Way Birth Center
Good Samaritan - Puyallup
Home Birth (travel fee may apply based on your location)
Lakeside Birth Center - Lake Tapps
Madigan Army Medical Center - JBLM (+$35 travel fee)
Multicare Auburn Medical Center
Multicare Capital Medical Center - Olympia (+$45 travel fee)
Multicare Covington Medical Center
Multicare Tacoma General
Moonrise Health & Birth Center - Mountlake Terrace (+$40 travel fee)
Other (travel fee may apply based on your location)
Overlake Medical Center - Bellevue (+$30 travel fee)
Providence Pavilion for Women & Children - Everett (+$55 travel fee)
Providence St. Peter Hospital - Olympia (+$45 travel fee)
Puget Sound Birth Center - Kirkland (+$35 travel fee)
Rainier Valley Birth Center - Renton
Sprout Birth Center - Mountlake Terrace (+$40 travel fee)
St. Anne Hospital - Burien
St. Elizabeth Hospital - Enumclaw
St. Francis Hospital - Federal Way
St. Joseph Medical Center - Tacoma
St. Joseph Midwifery Birth Center - Tacoma
Swedish Ballard Medical Center (+$35 travel fee)
Swedish Health Edmonds (+$45 travel fee)
Swedish Health First Hill (+$25 travel fee)
Swedish Health Issaquah
The Birth Cottages - Enumclaw
The Birth House - Olympia (+$45 travel fee)
The Birthing Inn - Tacoma
UW Medical Center - Montlake (+$40 travel fee)
UW Medical Center - Northwest (+$40 travel fee)
Valley Medical Center - Renton
Virginia Mason (+$25 travel fee)
If "other" is selected above for planned birth location, please add below
Will this be your first birth?
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Yes - Primip
No - Multip
Single or Multiple pregnancy
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Single
Monochorionic Twins (one shared placenta)
Dichorionic Twins (two placentas)
Have you encapsulated your placenta in the past?
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Yes, with you!
Yes
No, this is my first time
How did you hear about my services, did anyone refer you? Any additional notes?
Choice of Placenta Encapsulation Package
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Essential Package $375 - Placenta Capsules
Healing Package $400 - Placenta Capsules & 4 oz Placenta Tincture
Nurturing Package $425 - Placenta Capsules, 4 oz Placenta Tincture, 80 Organic Herbal Lactation Support Capsules & Postpartum Herbal Bath
Added herbs for the Steamed & Dehydrated Method
These are the optional add-on herbs which will be added during the steaming process for the Steamed & Dehydrated Method ONLY.
Organic Lemon
Organic Ginger
Organic Cayenne Pepper
Additional Add-On Options
These are in addition to what is included in your chosen package above.
Complimentary Cord Keepsake
4 oz Placenta Tincture $45
Herbal Lactation Support Capsules (80 capsules) $32
Herbal Lactation Support Capsules (160 capsules) $53
Herbal Lactation Support Capsules (320 capsules) $95
Elderberry Syrup DIY Kit - Original $17
Elderberry Syrup DIY Kit - Super Immune Boost $20
3 oz Postpartum Herbal Bath - 2 Full Soaking Baths $20
Separate processing for twin placentas. Will process and bottle each placenta separately $75. Otherwise standard processing of twin placentas together is no additional charge.
Entire Agreement
*
ENTIRE AGREEMENT
This agreement contains the entire understanding between The Nurtured Leaf, LLC, and/or Alecia Smith, and The Client. It supersedes all prior and simultaneous agreements between the parties. The only way to change or add to this agreement is to do so in writing with all the relevant parties signing provided document.
RESERVATION
Upon submitting the non-refundable deposit payment and agreement form, The Nurtured Leaf, LLC will reserve 4 weeks surrounding The Client's due date on their calendar. For this reason, the deposit payment of $100 will remain non-refundable even if services are not rendered for any reason.
PAYMENTS
The Client agrees that a non-refundable $100 deposit fee is due in advance of the completed Agreement Form, and is required to reserve services. This deposit payment is applied to the total placenta service purchase. Remaining balance is due upon pickup of the placenta to The Nurtured Leaf, LLC for chosen encapsulation services. If the remaining balance payment is not paid in full upon pick up of the placenta for preparation, delivery for services rendered and products purchased will not be delivered to The Client until the balance is paid in full. Tax is not charged to the deposit payment but will be added to the final payment due for services rendered.
METHOD OF PAYMENT
Payment may be made either by cash, check, Venmo or via a credit card. A $35 fee will be charged for all returned checks. A 3.5% Convenience Fee will be charged for all credit card payments.
TRAVEL
Travel time is included in the encapsulation fee for the Full Service Encapsulation Package unless over 30 miles from zip code 98022. Location will be agreed upon during booking and if location is farther than 30 miles, a travel fee of $25+ will be incurred depending on location. If there is a location change after the Agreement Form has been signed and it is outside of the standard 30 mile travel radius, a travel fee will be charged. If there is a location change after the Agreement Form has been signed that is further than the applied travel fee, the travel fee will be adjusted to reflect the additional distance.
CANCELLATION & REFUND
No refund is given for services canceled. If The Nurtured Leaf, LLC is unable to provide placenta services due to illness or is otherwise incapacitated, all efforts will be made to send a qualified back-up specialist. Contract will then be taken over by the back-up specialist. If The Nurtured Leaf, LLC is unable to provide services and no back up specialist is available, the deposit will be refunded in full. It is The Client’s responsibility to get permission for release of the placenta from care provider. If The Client is unable to obtain the placenta or it is contaminated before release and unable to be consumed for any reason beyond The Nurtured Leaf, LLC's control, there is no refund of deposit. Once The Client has called The Nurtured Leaf, LLC to come pick up the placenta, full payment is due. If the placenta was misplaced, not saved by care provider, or unusable; but The Nurtured Leaf LLC is already enroute to pickup, The Client will receive an invoice for $100 and the $100 deposit fee will remain non-refundable.
CLIENT RESPONSIBILITIES
The Client will notify their care provider during a prenatal visit that they plan to keep their placenta. If their care provider requires a release form to be signed for the release of the placenta, they will provide The Client with one (hospital birth). The Client agrees to contact The Nurtured Leaf, LLC as soon as labor begins and then again after baby is born. The client is to contact The Nurtured Leaf, LLC via text message. Pickup hours are between 7 am and 7 pm. As long as The Client has contacted The Nurtured Leaf, LLC by 7 pm, their placenta will be picked up on the same day, otherwise a time will be arranged for the placenta to be picked up the following morning. The Client will be given proper handling and storage instructions upon reserving services, which will include safe storage instructions for holding the placenta overnight if necessary. The Client agrees to keep the placenta in their sight at all times to ensure it does not go to a lab where it could be contaminated by chemicals or other harmful substances rendering it unsafe for consumption. If the hospital must test the placenta, a small piece can be taken off the maternal side and sent to the lab, while the intact placenta is stored properly. The Client agrees to have the double bagged placenta placed in a refrigerator (home birth) or cooler with ice (hospital or birth center), within 1 hour of birth. If The Client has reserved services with The Nurtured Leaf, LLC at least 3 weeks in advance of their estimated due date, they will receive a personal placenta storage and transportation kit. The Client is responsible for packing along the provided placenta transportation kit along with them, for the birth. If The Client has reserved services less than 3 weeks of their estimated due date, The Client is responsible for providing a cooler to properly store their placenta in. The placenta should sit out for no more than a maximum of 4 hours at room temperature. Ideally, the placenta should be placed on ice or in a refrigerator within 1 hour of birth. If The Client is unable to contact The Nurtured Leaf, LLC within 3 days of the birth, The Client should freeze the placenta until they are ready for it to be picked up. A frozen placenta will take additional time to prepare, so that it can be safely thawed. The Client understands that the same post birth care instructions apply to C-Sections.
WASHINGTON STATE LEGALITIES
There are no State mandated regulations in Washington barring placental release or consumption. The place of birth may have policies and may require a release form. The Client is responsible for determining the policy of their birth place during pregnancy and informing the care provider that The Client plans to keep their placenta.
RISKS OF PLACENTA CONSUMPTION
The Client understands the risks of placenta consumption are the same as dining out in a restaurant where the food is prepared. Other risks may include: placenta being switched with another placenta that is not The Client’s at the hospital; placenta contamination with chemicals at the hospital pathology laboratory; and contamination during transport (either by hospital or The Client failing to store properly).
POSSIBLE BENEFITS OF PLACENTA CONSUMPTION
The Client acknowledges the following possible benefits of placentophagia / placenta encapsulation:
• Preventing and lessening the risk of postpartum depression or “baby blues”
• Replenishing iron from blood loss during birth and prevention of post birth anemia in the mother
• Lending a consistent flow of oxytocin (the love hormone) long after the birth euphoria ends
• Provides the HPL hormone to help establish early and healthy milk supply for breastfeeding
• Stabilizes constantly fluctuating hormones post birth
• Replenishes B vitamins and energy that were used during the labor and birth process
• Protection from infection and bleeding due to retained placenta tissue or membranes
• Offers natural pain relief from the labor and birth process via the hormone POEF (placenta opioid enhancing factor)
WAIVER OF LIABILITY
The Client understands that choosing to encapsulate their placenta is not intended to prevent or treat any physical or mental diseases, ailments or symptoms and that The Client is choosing to consume their placenta for their own personal beliefs, whether it is spiritual or cultural. The Client acknowledges that The Nurtured Leaf, LLC has provided concrete information about the benefits and risks of placenta encapsulation and has read all included documents. The Client understands that the placenta has been handled and encapsulated according to OSHA and WA Food Safety and Handling standards, has been rinsed with clean water, steamed (if this preparation method has been chosen), dehydrated and put into capsule form in a sanitary and disinfected work space. Upon receiving placenta capsules or other placenta products, The Client waives any and all rights to hold The Nurtured Leaf, LLC and/or Alecia Smith responsible for any undesired effect of consuming the capsules. The Client does not hold The Nurtured Leaf, LLC and/or Alecia Smith responsible or liable for any transport mishap that is beyond their/her control (ex: car accident or detainment). The Client understands that the placenta will be prepared in The Nurtured Leaf, LLC's dedicated workspace and returned to The Client as soon as their chosen package has been completed. Preparation typically takes 2 days. The placenta will be prepared in The Nurtured Leaf, LLC's dedicated workspace, and The Client places full trust and acknowledgement that it is being handled in a sanitary and safe environment. The Client understands that upon receiving placenta capsules and products, The Nurtured Leaf, LLC and/or Alecia Smith are no longer liable, including but not limited to any other persons ingesting The Client’s placenta.
DISCLAIMER
Alecia Smith/The Nurtured Leaf, LLC is not a licensed medical professional and is not able to diagnose, treat or prescribe for any health condition. Services and fees are for the preparation and encapsulation of The Client's placenta, not for the sale of the capsules. No specific benefits or effects are promised. Any benefits will vary from person to person. Some of the ascribed benefits of placenta consumption are supported by research; however these benefits have not been evaluated or approved by the Food and Drug Administration. It is The Client's responsibility to determine whether using placenta preparations may be of benefit to them. The Client should always speak to their care provider regarding any questions about health, safety and well-being. Placenta services are not meant to be a replacement for medical advice or prescription medicines. If The Client is experiencing symptoms of postpartum depression, low milk supply, or other medical concerns, The Client should speak to their care provider.
Yes, I agree by typing my name in below
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