shannon bacus birth doula services

Placenta Encapsulation + Tincture Services Client Contract *

Please complete the following Client Registration, read carefully through the General Information and Policies, and note any information related to your services that I should be aware of. Please check where indicated and choose your appropriate response. Finally, electronically sign your name & the date at the end, then proceed to pay online. I respect your right to privacy and assure you that all answers are held in strictest confidence.

I agree!

Mother's Name *

First Name

Last Name

Phone *

(###)

###

####

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of partner or support person who may contact me about your placenta *

First Name

Last Name

Partner/Support Persons's Phone Number *

(###)

###

####

Baby's Due Date *

MM

DD

YYYY

Address of Planned Birth Place *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Will this be your first birth? *

Yes

No

Are you allergic to latex? *

Yes

No

Do you have any food or environmental allergies? *

Yes

No

Have you had any of the following during this pregnancy? *

Please check all that apply even if you have been treated. Make a note in the "Other" category if you have a history of the following or any that are not listed.

None

Group B Strep (GBS+)

Hepatitis A/B/C

MRSA

HSV

HPV

Urinary Tract Infection (UTI)

Other STD/STI (Chlamydia, Gonorrhea, HIV, Other)

Service Location & Method *

I am a certified Placenta Encapsulation Specialist through APPA. As your trained and qualified placenta encapsulationist, I exclusively prepare your placenta with the Traditional Method and in my dedicated workspace. Preparation of your capsules requires two days to complete and involves the use of chemical sanitization methods. Please check both below to agree:

1. Preparation is done in my dedicated workspace used exclusively for encapsulation.

2. Traditional (steamed) capsules.

Investment *

The fee for encapsulation + tincture services is $350. A $50 non-refundable retainer fee is assumed upon electronically signing this contract. Refund policies are listed below in full.

I understand and agree to pay!

Cord Keepsake *

A free cord keepsake is included in your package. This is optional. Would you like a cord keepsake?

No, Thanks!

Yes, Please!

Placenta Tincture *

Placenta Tinctures are made with grain free alcohol and have been reported to have similar benefits as the capsules, and has an indefinite shelf life if properly stored. The tincture can be used once a woman's cycle has returned and some moms report the tincture can help manage symptoms of menopause.

Yes, I'd like to add this for $25 - Making my final total $350.

Preparation *

Talk to your care provider during a prenatal visit about your intended birth place’s policies in regards to releasing the placenta. Sign any forms required and have them placed in your file. If you are birthing in a hospital: remind your labor nurse upon arrival, and on change of shift if applicable, that you plan to take your placenta. Following the birth, your placenta must be double bagged in 2 Ziploc gallon-sized bags and labelled with your name. The placenta should then be placed on ice and stored in a cooler within 2 hours of the birth. At your earliest convenience, the placenta should be moved to a refrigerator. You are responsible for ensuring that you have met all the requirements of your birthing facility and completed the appropriate paperwork for release, if any. You are responsible for the safe handling and appropriate storage of your placenta prior to the specialist beginning her work.

I agree!

Notification *

Call or text message me at 217.825.5296 after the birth to notify me that you have delivered. Please notify me between 7am and 9pm. If you are having a scheduled cesarean birth or an induction, please notify me ahead of time by email or text. If you are not able to contact me within 3 days of the birth and the placenta has been appropriately refrigerated since the birth, please freeze the placenta until you are ready for encapsulation to begin. Encapsulation and completion of the process generally takes 2 days for a refrigerated placenta. A frozen placenta will take an additional 1-2 days so that it can be safely thawed.

I agree!

Pick Up *

It is your responsibility (partner, parent, friend, relative, etc.) to meet me at the entrance of your birth place. As your encapsulation specialist, I will pick up your placenta at the entrance and safely transport it to my dedicated workspace. You must bring a disposable cooler and 2 Ziploc bags to your birth place. Your placenta must be put into one ziploc bag, and that bag be placed in the other ziploc bag. The double bagged placenta should then be sandwiched between ice (layer of ice in cooler, then the double bagged placenta, and more ice on top). When I arrive, I will take your placenta from your cooler and place into my transport cooler. Your placenta will be stored in my placenta-only mini-fridge until I begin the process.

I agree!

Processing *

Your placenta will be handled and encapsulated according to OSHA bloodborne pathogens universal precautions and Food Safety and Handling standards. Your placenta will be cleaned with water, steamed, dehydrated and put into capsule form in the sanitary and disinfected work space indicated above. The specialist is not responsible or liable for any issues preventing provision of the services that are beyond her control (ex. car accident, detainment, placenta sent to Pathology Dept., etc). If Placenta is sent to pathology, request that only a small portion be sent, and you keep the majority of the placenta. If the whole placenta is sent to pathology, it cannot be encapsulated due to lack of temperature control and chemicals used. If your placenta is sent to pathology a refund will be given minus the $50 retainer fee.

I agree!

Payment & Refund *

Payment is due in full when submitting the contract. You may cancel this contract at any time prior to services being rendered, with the retainer fee of $50 being non-refundable. If you cancel after I have arrived for pick up, but before preparation begins, I will keep the retainer fee and $75 service call charge will be reduced from the remaining balance of the total cost. If you cancel after the encapsulation process has begun, no refund will be given. No refunds are given for completed encapsulations.

I agree!

Non-Medical/Pharmacological Provider *

Your placenta specialist is not a pharmacy, pharmaceutical representative, holistic practitioner, herbalist, homeopath or medical doctor. Benefits of placenta encapsulation are supported by maternal experience and have not been evaluated by the Food and Drug Administration. Placenta Encapsulation or placentophagy is intended solely for ingestion by the mother who has birthed the placenta(s) and not for her family members, friends, or other individuals and is not guaranteed to produce specific results. The services offered are not clinical, pharmaceutical, or intended to diagnose or treat any condition. Families who choose to utilize the services take full responsibility of their own health and for researching and using the offered services. Your placenta specialist makes no guarantee as to capsule efficacy, but does guarantee the highest quality of service.

I agree!

Healthcare Provider *

Always speak to your care provider regarding any questions about your health, safety and well-being. Placenta services are not meant to be a replacement for medical advice, medical care or medicine. If you experience symptoms of postpartum depression, low milk supply, etc. please call your care provider to discuss your symptoms and how to feel better as well as treat any existing symptoms or potential conditions. While many women have found placenta encapsulation to be a wonderful and amazing gift, you are still encouraged to seek appropriate assistance and medical care when necessary. It is always okay to ask for help.

I agree!

Investment *

I agree that I am paying for the encapsulation + tincture service only, which is not clinical, pharmaceutical, or intended to diagnose or treat any condition. No refunds for completed services will be given.

I agree!

Safety *

My placenta does not contain any transmittable diseases such as Hepatitis-B, -C or HIV/AIDS. My care provider and I have determined that my placenta is healthy and suitable for encapsulation. The placenta has been handled in a manner appropriate for safe food preparation since the birth.

I agree!

Damage *

I understand that my specialist views each placenta as a sacred connection between mother and child and will treat it accordingly. I will not hold my specialist responsible if my placenta is accidentally damaged during the encapsulation process. No refund is given if damage occurs to unforeseen circumstances in the process, including equipment malfunction and human error.

I agree!

Usage *

My specialist does not determine whether my placenta should be consumed and makes no guarantee of my personal results from the capsules. The capsules should not be taken during times of illness, such as the common cold, flu, or mastitis. I understand that taking the capsules in any manner other than as labelled can have undesirable results.

I agree!

Record *

My specialist will keep this document on file as a record of our agreement. No copies will be released to any third parties and all client information will be kept strictly confidential. The information provided has not been evaluated by the Food and Drug Administration.

I agree!

Data *

I consent to statistical data collection that will be used exclusively by Shannon Bacus Birth Doula Services.

I agree!

Date of Signing *

MM

DD

YYYY

Payment *

Submitting your payment is the last step! Once you click submit below, you will be taken to an online platform to make your payment. Shannon will follow up within 24 hours by email to confirm your reservation.

I agree!