Name *

First Name

Last Name

Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birth Partner's Name *

First Name

Last Name

Birth Partner's Phone *

(###)

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2nd Birth Partner's/Doula's Name (if applicable)

First Name

Last Name

2nd Birth Partner's/Doula's Phone

(###)

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Standard delivery of the placenta chill pack takes 2-3 working days and is free. If you require express delivery, please tick here and add £7 to your total

Delivery of the capsules (and other remedies) once they are ready is free

Yes, please send the chill pack by express delivery

Have you been diagnosed with Group B Strep in this pregnancy? *

Yes

No

Don't know

Have you ever tested positive for AIDS/HIV, CJD, Hepatatis B, Hepatitis C? *

For your safety and mine, I MUST have an honest answer to this question.

Yes

No

Have you smoked at all during this pregnancy? *

For your health and safety, I MUST have an honest answer to this question.

Yes

No

Have you been prescribed regular medication during this pregnancy? *

Yes

No

If yes, you must seek approval from your prescribing doctor before your booking can be accepted. *

Have you got approval from your prescribing doctor?

Yes

No

N/A

Do you require any other placenta products?

Placenta Essence 200ml £45

Placenta Tincture 200ml £70

Homeopathic remedies 40c and 7c £65

Placenta Print £15

There will be an additional travel charge as you are out of my direct area. Please mark your hospital/place of birth on the following list:

Cheltenham £30

Gloucester £30

Reading £40

Stoke Mandeville £35

Stroud £30

Swindon £25

Wallingford £30

Wantage £25

Warwick £30

Worcester £40

Terms and Conditions *

1. By completing this booking form, you are requesting the services of Sarah Boyd, a Placenta Remedies Provider (PRP) who is trained by IPEN and insured to arrange or provide the placenta remedies chosen by you. 2. All placenta remedies are for your own personal use with the exception of the homeopathy made specifically for the baby, and the essence which can be used topically on the baby. 3. The benefits reported from consuming the placenta are anecdotal and without scientific evidence, so we cannot claim that mothers will receive them. Benefits noted are based on research studies, articles and testimonials. 4. PRPs are unable to process placenta services if you have a current or previous diagnosis for HIV/AIDs, Hepatitis B and/or Hepatitis C, CJD, or if you have smoked during this pregnancy. 5. To ensure safety for all, any equipment used in the process of providing placenta remedies to you is subject to current hygiene standards and regulations currently in place in the UK. Hand blenders used for placenta smoothies are ‘one use’ only and are then disposed of or given to the client. 6. The placenta will be stored correctly in line with the guidance provided by your PRP, and those guidelines shared with your midwife or doctor when packaging the placenta for transport. The placenta will be placed into the collection kit or a fridge within 30 minutes of birthing, and you agree to ensure the placenta remains chilled until collection. 7. Please contact your PRP as soon as possible after birth, and within 12 hours to arrange collection. 8. Your PRP cannot be held accountable if the placenta is unavailable for processing due to loss before she comes to collect it. If she is informed that she need not collect it (for any reason), the client will be refunded the fee paid, less an admin charge of £50. The client will be responsible for returning the chiller pack provided by the PRP within two weeks of the birth, and the refund will be paid once the pack has been received. 9. If, when she comes to collect the placenta, the PRP finds it has not reached less than 8 degrees Celsius (if it is more than 4 hours after the birth), she will not be able to create any remedies from it other than homeopathy, a print and an umbilical cord keepsake. She will not offer any refund in this situation. If the client is aware that the placenta has not been accurately stored immediately after birth, and informs the PRP that she need not collect it, the client will be refunded the fee paid, less an admin charge of £50. The client will be responsible for returning the chiller pack provided by the PRP within two weeks of the birth, and the refund will be paid once the pack has been received. 10. By ensuring that the chill chain has been completed fully by the client, and following all necessary procedures and hygiene protocols, the PRP cannot be held responsible for any results or effects experienced before, during or after consuming the placenta. 11. Full payment is due when the PRP accepts the booking. The chill pack will not be sent out until payment has been received. 12. By checking the box below the client agrees that all the information they have given is correct to the best of their knowledge. They also agree to the Terms and Conditions above and that they will thoroughly read and will follow all the guidelines in the documents provided in their collection kit to ensure the safe storage of their placenta.

Yes