Prices & Booking Form

This form requires personal information from you in order for The Placenta Element to provide a service to you. For full details on how The Placenta Element handles this data please see the privacy policy https://theplacentaelement.co.uk/privacy/ Fields marked with an asterisk (*) are required. *

I consent to The Placenta Element collecting the information in the form in order to provide a service I am requesting.

Installment plans to suit your budget are available *

Yes I would like to spread the cost of my placenta remedies

No thank you

£100.00 deposit secures your dates. Payment due by 36 weeks/or on collection of the placenta unless an arrangement has been set up prior to this.

Where did you find The Placenta Element? *

Other - please share here

Full Name *

Partner's Name

Email *

Street Name *

Town/City *

Postcode *

Mobile number *

Partner's mobile

Estimated date of arrival *

Name of midwife/doula and contact number *

Have you informed your midwife about placenta remedies? *

Yes

No

Have you smoked regularly during your pregnancy? *

Yes

No

For the health and safety of all concerned, we MUST have an honest answer to the following; Have you ever tested positive for HIV, Hepatitis B or Hepatitis C? *

Yes

No

Place of birth *

Birth Centre

Hospital

Home

Other

Booking Hospital *

Mileage is not charged on top, however a collection fee applies for some areas due to travel time and fuel costs. Alternatively, drop off can be arranged, contact Nikki for information.

Where did you hear about placenta remedies? *

Why are you interested in placenta remedies for yourself? *

Remedy Options - Choose one or more of the following options *

*Includes all equipment. Collection and preparation is at your home for Placenta Smoothies and Placenta Smoothie Packs. Installments can be made for any remedy choice. If choosing Smoothie Packs only without capsules there is a £50.00 disposal fee for the remaining placenta after smoothies are prepared.

Where would you like your collection kit to be sent? *

Address above

Another address

Please email the address if you would like your kit to be sent to another location

Delivery of remedies *

Please send my package Next Working Day Delivery after completion (Included)

Please hand deliver my package when completed - £50.00

1. By completing this booking form you are requesting the service (s) of a placenta remedies provider who is trained and insured to provide arrange or provide the remedies chosen by you. The placenta remedies chosen are for your own personal use. 2. The information available regarding the use of placenta remedies are based on research, anecdotal evidence and testimonials from those who have used them. We are unable to guarantee how your remedies will affect your personally, due to each placenta being individual and unique in composition. 3. We cannot be held responsible for and will not be liable for any unwanted effects or negative experiences you may experience before, during or after consuming the placenta unless those effects are from the direct negligence during the processing of the placenta. 4. Placenta Remedies Providers are unable to process placenta services if you have a current or previous diagnosis for HIV/AIDs, Hepatitis B and/or Hepatitis C. 5. Placenta Remedies Providers cannot provide remedies to anyone who has smoked during their pregnancy. 6. To ensure safety for all, any equipment utilised in the process of providing placenta remedies to you are subject to current hygiene standards and regulations currently in place in the UK. Hand blenders used for placenta smoothies are ‘one use’ only. 7. You agree that the placenta will be stored correctly in line with the guidance provided by your Placenta Remedies Provider, and those guidelines shared with your midwife or doctor when packaging the placenta for transport. The placenta will be placed into the collection kit or a fridge within 30 minutes of birthing, and you agree to ensure the placenta remains chilled until collection. 8. Please contact your Placenta Remedies Provider as soon as possible after birth, and within 12 hours to arrange collection. 9. Your Placenta Remedies Provider cannot be held accountable if the placenta is unavailable for processing due to loss or other reasons beyond influence. Should the situation be beyond control, only the booking deposit is retained. Any further payments which have been made will be refunded. If the placenta has not been stored correctly following instructions, the full fee is retained. 10. If contact with your Placenta Remedies Provider is delayed and the placenta is unsuitable for processing due to incorrect storage and handling, the full fee will be retained. Please refer to the Chill Guide for full instructions, which you will find in your Collection Kit when it arrives. 11. You agree to complete an online questionaire sent to you 6 weeks after you receive your remedies and commit to answering the questions honestly to help support the feedback process of placenta remedies. 12. Full payment is due at 37 weeks or upon collection of the placenta. 13. By checking the box/signing below you agree that all the information you have given is correct and is to the best of your knowledge. You also agree to the Terms and Conditions above and you will thoroughly read and will follow all the guidelines in the documents provided in your collection kit to ensure the safe storage of your placenta. I agree to the terms above *

No

Yes

Processing of your form cannot be completed without your agreement.

Cheshire Placenta Remedies Provider offering services across the North West

Booking Form