Intake Form and Placenta Contract

Client Name *
Client Name
Spouse (if applicable)
Spouse (if applicable)
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Address
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Home Phone
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Provider's Phone
Provider's Phone
Placenta Contract
The purpose of this contract is to outline all of terms and responsibilities by both me and you as my client. This contract can be changed to fit any needs you and your family needs. Letter of Agreement Describing All Placenta Services There are two common ways of encapsulating the placenta, the Traditional Chinese Medicine (TCM) method and holistic method. The TCM method is when the placenta is rinsed and steamed with a jalapeno pepper, lemon and ginger. Then thinly sliced and placed in a dehydrator to kill any bad bacteria. After they are completely dehydrated the strips are ground extremely fine and placed into vegetarian size “0” capsules. By steaming it with these ingredients it can have a warming and soothing effect on women. The holistic method is when the placenta is rinsed and sliced into strips and placed directly in the dehydrator. This is believed to keep possible nutrients that may be lost in the TCM method. Placenta Tincture is also something that women prefer to do. This is when a walnut size piece of the placenta, which is lightly steamed, is placed in high grade alcohol for 6 weeks. This preserves all of the benefits of the placenta that will last after the placenta pills are gone or in place of the placenta pills. Placenta Salve is a balm made from a small dehydrated piece of the placenta. It contains; dried ground placenta, organic sunflower oil, organic extra virgin coconut oil, beeswax, vitamin E oil, lavender essential oil, tea tree essential oil and the essential oil blend On Guard. Please type name below confirming that you have read and agree to the above.
The information on this page has not been evaluated by the Food and Drug Administration. The services I offer are not clinical, pharmaceutical, or intended to diagnose or treat any condition. Families who choose to utilize the services on this page take full responsibility for researching and using the remedies. I understand that I am responsible for letting Mary know if there was anything done to the placenta or any previous issues that may compromise the integrity of the placenta as a food grade item. Please type name below confirming that you have read and agree to the above.
Placenta options *
All fees must be paid before I will be able to take the placenta. The placenta may be frozen until thawed and encapsulated if needed. If the placenta needs to go to pathology please request that they only take a piece. If entire placenta goes to pathology, I may not be able to use it. If for any reason you no longer want the services above all but $40 retainer will be returned. I understand there will be a $0.50 milage charged applied for locations beyond 40 miles from my location. I am on call for your placenta from 36-42 weeks. During this time you can either text or call when labor begins and also after baby is born. I will pick up the placenta at the place of the birth and it will be processed and returned within 72hrs. Please type name below confirming that you have read and agree to the above.
Options *
Check below if you would like a placenta print or umbilical cord keepsake. Also select preparation method.
Any checks can be made out and sent to: Mary Nieland 1129 Taft Street Little Chute, WI 54140 Any check that is returned will have a $40 returned check fee. PayPal payments are also accepted when invoice is sent from marynieland@yahoo.com