Birthing Person's Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Person Assigned to Placenta Coordination

First Name

Last Name

Placenta Coordinator's Phone

(###)

###

####

May we coordinate with your doula?

Yes

No

Which method would you like to use for encapsulation?

Traditional Chinese Method replenishes chi (life force) by steaming the placenta with chilies, lemon, and ginger before dehydrating. The Raw Method requires all excess blood is massaged out of the placenta before dehydration begins.

Traditional Chinese Medicine

Raw Method

How would you like your tincture prepared?

With Alcohol

With Apple Cider Vinegar

Tincture?

Yes, please

No, thank you (final price is $25 cheaper)

Keepsake Placenta Print?

Yes, please

No, thank you

I have asked Camilla Rae to prepare my placenta for my own personal use and I take full responsibility for my own health. *

Correct

I understand that I am responsible for contacting Camilla Rae within 24 hours after birth to agree upon a time for her or her associate to retrieve my placenta. *

I Understand

I will ensure the placenta has been cared for and handled in a manner appropriate for safe food preparation. *

I Agree

My placenta does not contain any transmittable diseases such as hepatitis B, hepatitis C, or HIV/AIDS. *

I Agree

Camilla Rae does not determine whether my placenta is suitable for consumption and makes no guarantee of my personal results from consumption. *

I understand.

I ensure it is safe for Camilla Rae to move forward and process the placenta. *

I Agree

I release Camilla Rae and any assistants or processors from any and all liability for any effects I may experience and outcomes after choosing to consume my placenta. *

I Understand

I understand that to have Camilla be on call to receive my placenta that I am paying a $75 non-refundable deposit. In the event that we don't decide to encapsulate. The remainder of payment, beyond the $75, will be returned. *

I understand.