client intake form for placenTa encapsulation

Expectant Mother's Name *

First Name

Last Name

Phone Number *

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Preferred Method of Contact *

Email

Text

Phone Call

Estimated Due Date *

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Mother's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Planned Location of Birth *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you currently negative for all STDs? *

Yes, I am negative for all STDs

No, I am positive for one (1) or more STDs

You will email, text or personally show Jenifer of Nova Rising your STD results or a doctors note stating that you are currently negative for STD(s) before your placenta is prepared. *

Yes, I will provide proof of my STD status

No, I will NOT provide proof of my STD status

I am not a licensed medical professional such as a care provider or physician and I am not able to diagnose, treat or prescribe for any health condition. Services and fees are for the service of encapsulating your placenta, NOT for the sale of the capsules. Each woman will react to her placenta capsules in different ways. Some of the ascribed benefits have not been evaluated or approved by the United States government or FDA. It is your responsibility to determine whether using placenta capsules can be beneficial to your wellbeing postpartum. *

YES, I UNDERSTAND

NO, I DO NOT UNDERSTAND

It is your responsibility to inform me of any known blood borne illness(es) or other health issues (such as HIV, Hepatitis etc.) that could place me or any others who may come in contact with your bodily fluids (specifically maternal and fetal blood as well as amniotic fluid) at risk. Some specific sexually transmitted diseases such as hepatitis or herpes may preclude me from offering placenta encapsulation in my home. *

YES, I UNDERSTAND

NO, I DO NOT UNDERSTAND

My responsibilities include maintaining client confidentiality, committing to preparing and returning your capsules within 72 hours of receiving your placenta (usually 24-36 hours) and upholding the highest standards of cleanliness, safety and quality of professional placenta preparation services. *

YES, I UNDERSTAND

NO, I DO NOT UNDERSTAND

It is important to understand that there may be circumstances in which your placenta cannot be used. Significant abnormalities of the placenta may necessitate your doctor or midwife sending your placenta to Pathology for further examination. Once the placenta has been released to Pathology, I will NOT be able to encapsulate without an additional waiver. Other conditions, such as signs of infection in the mother during labor, may mean that consuming your placenta could be harmful to your health. I will always consult with you prior to making a choice on whether or not your placenta is viable for ingestion. It is important that you let me know if you have any health concerns or conditions which may affect the health of your placenta or the health and safety of others who may come in contact with your placenta. *

YES, I UNDERSTAND

NO, I DO NOT UNDERSTAND

If I have already taken possession of your placenta and you choose to not go forward with services, I will return your placenta to you and you will be given a full refund (less) minus $100.00 (Any travel fees are non-refundable) for consultation, handling & travel. If for whatever reason you decide to forgo my services before I have taken possession of your placenta, you will be given a full refund (less) minus $50.00 for consultation & travel. There will be NO REFUND once preparation has begun, even if you choose not to take delivery of the finished placenta capsules/goods. *

YES, I UNDERSTAND

NO, I DO NOT UNDERSTAND

I have read, understood and agreed to the above information. By electronically signing below I authorize the release of my healthy placenta to Jenifer Brown; Nova Rising, for purposes of placenta encapsulation services and keepsake preparation for my own personal use. *

YES, I AGREE

NO, I DO NOT AGREE

Date Signed *

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I understand and acknowledge that in accordance to my state laws and bylaws, choosing to encapsulate my placenta is not intended to prevent or treat any physical or mental diseases, ailments or symptoms and that I am choosing to consume my placenta for my own personal beliefs, whether it be spiritual or cultural etc. I acknowledge that my placenta specialist has provided me with concrete information about both the benefits and risks of placenta encapsulation, and I have read all included documents. I understand that my placenta has been handled according to OSHA and State Food Safety and Handling standards, and has been cleaned, cooked, dehydrated, and put into pill form in a clean and sanitary work space. Upon receiving my placenta capsules and tincture from my placenta specialist, I waive any and all rights to hold the specialist responsible for any undesired effect of consuming the capsules/tincture. This may include an oversupply in milk, hormonal shift, anxiety or sleeplessness; these side effects are rare, but have been reported. I agree to contact my placenta specialist immediately if and when I experience any of these side effects. My specialist agrees to complete (2) postpartum follow-ups until 6 weeks postpartum. I do not hold my placenta specialist responsible or liable for any transport mishap that is beyond their control (ex. Car accident or detainment), and understand that I am choosing to have the specialist encapsulate my placenta. *

I Understand & Agree

I Do Not Agree

I put full trust and acknowledgement that it is being handled in a sanitary and safe environment. I put trust and faith that my placenta specialist has been professionally trained to correctly prepare placenta remedies. I have provided my placenta specialist with recent blood documentation stating that I have been tested for STD’s and the results were negative. Universal precautions for sanitizing are the same with each client, I understand and trust that my specialist retains blood work records for each client and that I am protected. I understand that upon receiving the pills, my placenta specialist is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules. *

I Agree & Understand

I Do Not Agree

Date Signed *

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