Placenta Encapsulation Contract

New Client Contract
Package *

Basic Preparation - $200 Sweet Memories - $225 The Restoratives - $275 Deluxe - $325
Placenta Preparation Format: *

Traditional Chinese Medicine Encapsulation RAW Encapsulation Placenta Cubes 50% TCM & 50% RAW 50% TCM & 50% Cubes
Capsule Options

Non-flavored gelatin capsules Non-flavored veggie capsules Berry flavored gelatin capsules Bubblegum flavored gelatin capsules Strawberry flavored gelatin capsules
Add-ons:

Tincture (add $25) Salve (add $25) Homeopathics (add $25) Truffles (add $20) Prints (add $20) Placenta Meal (add $30) Smoothie (add $20) Requested Pictures (add $10)
Allergy Information:
List any allergies here (particularly ginger, hot peppers, lemon): *

Personal Information
Name: *

First Name Last Name
Partner's Name:

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number
E-mail *
Due Date: *

Month Day Year Date Picker Icon
Number of pregnancies:
Have you encapsulated in the past?
Any complications in this pregnancy? *
Sex of baby
Records of STD blood panel *
How was STD blood panel provided to specialist? *
How did you hear about my services?
Why have you chosen to use placenta services for your postpartum health? *

Care Provider
Care Provider: *
Name: *
Place of Birth *

Place of Birth *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number
Client informed care provider of consumption? *
Care provider was supportive? *

Terms and Conditions
Cancellations & Refunds:
In the event the placenta is unavailable (for example, it is not release from the hospital or it is sent to pathology) the deposit will be refunded, if this agreement is terminated before the release of the placenta to the encapsulator, any fees will be returned except for administrative costs. If the contract is terminated after release of the placenta to the encapsulator, but before any preparations have begun, it will be returned and the $50 deposit will be retained. Any other payments that have been made will be refunded. There will be NO REFUNDS and payment will be due in full once the preparations have begun. If Bethany Loper (A Breathataking Beginning) is unable to provide services due to illness or is otherwise incapacitated, the deposit will be refunded in full.
Please read and sign the Terms and Conditions below to confirm your booking for a placenta encapsulation with A Breathtaking Beginning.
I, (name) *
agree to the following:
- Arrange for someone to contact Bethany Loper (A Breathtaking Beginning) following the birth of my baby.
- I will inform my provider about my plans to keep and encapsulate my placenta
- I will inform my provider if Bethany Loper (A Breathtaking Beginning) will be picking up my placenta, in addition to signing any release forms.
I understand that encapsulations are said to last indefinitely although some say they need to be replaced every 2-6 years. I understand the process to prepare, dehydrate, grind up and encapsulate the placenta will take approximately 2 days.

I understand that I take full responsibility for my own health and for researching and using the remedies provided by this service. I agree that Bethany Loper (A Breathtaking Beginning) is not liable and does not take responsibility for any results or effects I may experience before, during or after consuming my placenta.
I understand that travel time is included in the encapsulation fee unless over 90 miles. Location will be agreed upon during booking and if location is farther than 90 miles, a travel fee will be agreed upon depending on location. If location changes after contract is signed and is out of the 90 mile radius, a fee will be charged. I am responsible for covering additional fees and costs related to location choice (admission fees, parking fees, etc.)

I understand that it is my responsibility to keep the placenta fresh. It can remain at room temperature for 3-4 hours following the birth. After that (or as soon as possible) it should be placed in a refrigerator or kept cool. If I plan a lotus birth or some form of delayed cord cutting, ice packs may be wrapped up with the placenta to prevent spoilage. If the placenta will take more than 3 or 4 days before it can be prepared, it should be placed in a freezer

I understand that I must furnish A Breathtaking Beginning (Bethany Loper) with a copy of my prenatal screening that includes STD results. It is safe to consume my own placenta if i am positive for an STD, but encapsulation will take place in my home and with my materials. It is not recommended that I stare my placenta products with anyone else when positive for an STD. A Breathtaking Beginning (Bethany Loper) abides by all HIPAA privacy laws and does not share my personal information.

I understand that there are NO state mandated regulations in Texas barring placental release or consumption. The place of birth may have policies and may require a release form or court order. I am responsible for determining the policy of the birth place during pregnancy and informing my care giver that I plan to consume my placenta.

I understand that the risks of placenta consumption are the same as dining out in a restaurant where food is prepared for me. Other risks include: placenta being switched with another placenta that is not mine at the hospital; placenta contamination with chemicals at the hospital pathology laboratory; and contamination during transport (either by hospital or me failing to store properly).

A Breathtaking Beginning (Bethany Loper) is not responsible for any adverse reactions to my placenta capsules. I have informed them above of my allergies.

I understand that when the placenta encapsulation process takes place in my home, the placenta will be left to dehydrate for several hours. A Breathtaking Beginning (Bethany Loper) is not responsible for any fire damages that may occur.

I understand that the act of ingesting placenta in any form has not been tested, nor approved by the FDA, and I ingest at my own risk. Furthermore, I release Bethany Loper (A Breathtaking Beginning) from any liability.

I understand the recommended dosage and usage of placenta capsules. I should not exceed 9 capsules per day and should stop taking them if I am sick.

I have read and agreed to all documents contained in this contract and folder including but not limited to: contact and FAQ information, current pricing, hospital release information, liability waver, photo release form, placenta information and benefits, alternative forms of cord cutting, and services offered.
Printed Name: *
Signature *

Clear
Date Signed *

Month Day Year Date Picker Icon

Liability Waiver
I, (name), *
understand and acknowledge that according to Texas law, 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. I also understand that there are no current laws, regulations or policies preventing me from obtaining my placenta from the place of birth.

I acknowledge that Bethany Loper (A Breathtaking Beginning) has provided me with concrete information about both the benefits and risks of placenta encapsulation, and have read all included documents. I understand that my placenta has been handled and encapsulated according to OSHA and Texas Food Safety and Handling standards, and has been cleaned, cooked, dehydrated, and put into pill form in a sanitary and sterile work space. Upon receiving my placenta capsules from Bethany Loper (A Breathtaking Beginning), I waive any and all rights to hold the specialist responsible for any undesired effects of consuming the capsules.

I do not hold Bethany Loper (A Breathtaking Beginning) 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:
Location *
If my placenta is not encapsulated in my own home, I put full trust and acknowledgement that it is being handled in a sanitary and safe environment. I have provided Bethany Loper (A Breathtaking Beginning) with blood documentation stating that I have been tested for STD’s and the results were negative. I understand and trust that Bethany Loper (A Breathtaking Beginning)retains blood work records for each client and that I am protected.

I understand that upon receiving the pills, Bethany Loper (A Breathtaking Beginning) is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules.
Mother's Printed Name: *
Mother's Signature: *
Date signed: *

Month Day Year Date Picker Icon

Release for Photography
I, (name), *
give my permission for Bethany Loper (A Breathtaking Beginning) to take photographs of my placenta. I understand that these photos may be used for record keeping, education, peer review, or promotional purposes. Identifying information will not be shared.
*

I/We DO NOT give permission for photography to be taken. I/We give permission for photography to be taken.
In addition,
*

I/We give permission for Bethany Loper (A Breathtaking Beginning) to use my/our photographs for marketing purposes, including, but not limited to, websites and portfolio creation. I/We DO NOT give permission for Bethany Loper (A Breathtaking Beginning) to use any of my/our photographs for any reason.
I/We would like to request copies of photographs taken for my/our own personal use. I/We understand that these will be transferred to a CD/DVD/USB.
Notes/Requests
Signature *
Date *

Month Day Year Date Picker Icon

Payment Method
A deposit of $50 is due with signed contract, with the balance payable in payments or upon receipt of the finished product. This deposit applies to your total placenta services purchase. This deposit will also reserve the time and date agreed upon. For this reason, the encapsulation deposit of $50 is non-refundable, even if the service is canceled for any reason.Payments may be made by personal check (made payable to Bethany Loper), cash, credit card, or PayPal (on client site).
Payment Method *

Cash Check Credit/Debit/PayPal
If multiple payment arrangements have been discussed with Bethany Loper, please outline them here:
My Products

Deposit $ 50.00

Discounted Payment (if agreed upon for other services) $ 150.00

Full Payment $ 200.00

Total $ 0.00
Should be Empty:

New Client Contract

Cancellations & Refunds: