Copy and paste the form below, print, fill out and mail to:


Mother's Love

3003 River Rd

Grand Rapids, MN 55744

Or email to [email protected]


  

ISSUED:


ITEM QUANTITY PRICE TOTAL


Professional Placenta Encapsulation Services $250.00 -includes timely pick-up of your placenta at the location you give birth, safe & professional       encapsulation of your placenta using the method you choose, and delivery of finished capsules within 72 hours of pick-up. This package includes capsules only.

□ Out of Service Area Travel Fee $50.00  -This fee includes pick-up of your placenta, professional processing and next-day shipping of your finished capsules.

□ Twins $50.00-This fee is for the added time and supplies for encapsulation.


Select One

You must pick one of these options:     

Placenta Encapsulation Services Holistic Method  

The placenta is processed using a “less is more” approach,

simply sliced and dehydrated, the placenta is then ground and

placed into capsules.


Placenta Encapsulation ServicesTraditional Method  

The placenta is gently steamed and then dehydrated. This process

has been used in Traditional Chinese Medicine for thousands of years.

It is thought the placenta is more “warming” when processed this way.

The Traditional Method generally yields about 125-140 pills.


½ & ½ Processing $50.00

For clients that don’t have an obvious preference for one processing

method or another. We will prepare half of your placenta according to

Traditional Method and half according to the Holistic Method.


Additional Options

You may pick any (or none) of these options:

□ Flavored Capsules $20.00

Base package services are made with a high quality clear

gelatin capsule. You can have your placenta encapsulated in

flavored gelatin capsules for a small fee. The upgraded

capsules are fruit scented and colorful.


□ Vegetarian Capsules $20.00

Base package services are made with a high quality clear gelatin

capsule. You can choose a vegetarian capsule instead for a small

fee.


□ Placenta Tincture

A small amount of your placenta is preserved in high proof alcohol – $25.00

creating a shelf stable placenta remedy for use long after your pills

are gone! One dropper will help ease hormonal imbalances caused

by the return of your menses, menopause or stress.


□ Placenta Printmaking $15.00

A print of your placenta- this is creating a print directly from your

Placenta on art quality paper for you to keep or frame.

     

 SUBTOTAL:

TOTAL:






Mother’s Love Placenta Encapsulation Agreement

Client Authorization


I, _____________________________, authorize__________________________ (birth facility) to release my placenta to Mother’s Love Placenta Encapsulation for the purposes of encapsulation. I acknowledge that all employees of MLPE are IPPA certified in this service and hold current certification in blood borne pathogens and food handling and accepts the risks to self with regards to the handling of this specimen. I authorize the keeping statistical information regarding my placenta that is non-identifying to me or my family.

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Limitations and Disclaimer

Amanda Bostyancic and Katie Schuster are not licensed medical professionals nor are we able to diagnose, treat or prescribe for any health condition. No specific benefits or effects are promised. Benefits will vary from person to person. Many of the ascribed benefits are well supported but none have been evaluated or approved by the FDA. It is your responsibility to determine whether using placenta preparations may be of benefit. A prenatal bloodwork must also be reviewed by us for notation for your protection as well as ours due to cross contamination.

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Service Agreement (select which one(s) apply)

□ Pick-up and delivery of your placenta at an agreed upon time and return completed capsules to you within 72 hours. ($250)

□ Travel Fees $50 + up

Mother’s Love Placenta Encapsulation offers pick up and drop off service to Grand Rapids and Deer River MN hospitals and birth centers at no charge as well as to home locations within 30 miles of downtown Grand Rapids. If you live outside the service area there is an extra fee for pick-up of your placenta. After processing your placenta we will ship UPS to your home address. Please allow extra time for out of area service requests.


Client Responsibility

The client is responsible for proper care of the placenta until arrangements are made for pick-up. The client has been directed to store the placenta in their hospital room in a Ziploc bag inside a cooler they provide and on ice at safe food temperatures (under 40 degrees) until it is released to Mother’s Love Placenta Encapsulation. The client has agreed to contact MLPE as soon as feasible after the birth of their child(s).


Processing Methods (choose one)

Holistic Encapsulation Method (Raw Start) – this method involves slicing the placenta while fresh and raw and dehydrating it immediately. Clients who choose this method more consistently report increased energy as one of the benefits. It is widely held that the hormones are more likely to be bioavailable when the placenta is processed at the lowest safe temperature. This is the most common method of placenta encapsulation requested. This method is not available if there are any concerns about the correct safe storage of the placenta before Amanda Bostyancic or Katie Schuster takes possession of it.

Traditional Processing (TCM) – In this method, your placenta will be steamed and then dehydrated. This is to enhance its warming properties and help your body use the beneficial properties of the placenta in a deeper way. This method also kills any bacteria and reduces risk of spoilage. However, there is concern about the degradation of the hormones when cooking the placenta. If there are any concerns about the proper storage or handling of your placenta, this is the only processing method available.


Fees and Refunds

A non-refundable $50 deposit is required at the prenatal visit. Payment can be made in person before birth or at pick-up/delivery by cash, check or credit card. Payments made by credit cards will include a 2.75% fee of the total due. (This is what we are charged for each swipe) Requests for payment plans or other arrangements must be made in advance.

Once we have taken possession of your placenta and this contract is signed, there will be no refund and payment in full will be due, even if you choose not to take delivery of the finished capsules.

Should an error in processing occur or if for some reason we are unable to complete the services as contracted, there will be no charge for any partially completed work and the client will be given the option of taking the placenta back for an alternative use if possible or we will dispose of it according to the local and state regulations regarding biohazardous waste.

Photography and Marketing Release

I grant Mother’s Love Placenta Encapsulation to photograph or otherwise document my placenta in its entirety or during processing for any marketing campaign including use on internet, website or print materials. My placenta will not be used in any way that identifies me as its owner. I allow Mother’s Love Placenta Encapsulation to use any testimonial I provide for any purposes. I waive any right to inspect or approve the content beforehand.

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Today’s Date: _________________________

Estimated Due Date: _____________________

Email Address: _________________________

Phone Number: _________________________

Address: ______________________________