Name *

First Name

Last Name

Phone *

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Estimated Due Date

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Add ons for Essential Package ($25 each)

Placenta Print

Tincture

Healing Salve

Unless otherwise specified, $100 is due at the signing of this contract. The remaining balance is due before or upon pick up of the placenta. *

I agree

If the client chooses to terminate the contract, thereby voiding the agreement, the client must contact BHM Born BEFORE the 38th week of pregnancy in order to receive a full refund of any funds *

I agree

If the client chooses to terminate the contract after the 38th week of pregnancy, the deposit of $100 will be retained by BHM Born (if the client paid more than the deposit, BHM Born will refund the difference). *

I agree

If the client determines they do not want the finished placenta pills AFTER BHM Born has picked up the placenta and begun the encapsulation process, or if the process has been completed, the client will not be refunded any money and will still ow the remaining balance (if it has yet to be paid). *

I agree

BHM Born is not a pharmacy, pharmaceutical representative, holistic practitioner, herbalist or medical doctor. Benefits of placenta encapsulation are supported by ongoing research but have not been validated by the FDA. Human encapsulation, as it pertains to this agreement, is for natural nutritional supplementation and is intended solely for ingestion by the mother who has birthed the placenta (s) and not for family members, friends, or other individuals. Prepared capsules are meant for natural nutritional supplementation and as such cannot be guaranteed to produce specific results. *

I agree

BHM Born will pick up the client's placenta(s) within 24 hours of delivery. Proper cleanliness and preparation precautions for ingesting the placenta will be carried out to ensure the highest quality of encapsulation possible. BHM Born will deliver the finished encapsulated placenta pills along with any other preparations within 72 hours after pickup. BHM Born will provide written instructions for storing the finished pills and suggestions for daily ingestion recommendations. *

I agree

It is the client's responsibility to notify BHM Born as soon after the birth as possible (preferably same day) to request pick up of the placenta(s) at the location agreed upon by both parties. Failure to contact BHM Born may result in delayed placenta preparation and encapsulation and may cause decreased potency of nutrients, hormones, and other beneficial attributes of the placenta(s), and even spoilage of the placenta(s), which would render it unusable for encapsulation. *

I agree

The client must discuss release of the placenta(s) after her birth with her care provider and ensure proper storage (place the placenta in a bag on ice and refrigerate or keep in a cooler, do NOT freeze) until it can be picked up or delivered to BHM Born. *

I agree

The client must inform BHM Born of any known blood-borne illness(es) or other health issues that the placenta encapsulation specialist may become infected with through contact with bodily fluids (specifically maternal and fetal blood and amniotic fluid), such as HIV, Hepatitis, STIs, etc. *

I agree

I agree:

First Name

Last Name

Date

MM

DD

YYYY