Please complete the form below before collection and ensure any balance due is paid before the collection occurs. Thank you. Placenta Collection Form Name of Mother/Parent * Date of Birth (Baby) * Placenta Birthed at (Time) Was Meconium present? * Yes No Chosen Remedies * Simple Capsules Steamed Capsules Smoothie Packs Single Smoothie 50/50 Capsules Tincture Homeopathy Other Other.... I can confirm that my placenta has been: • Birthed on to a clean surface/incopad • Stored as per the Placenta Remedies Providers chiller pack/cold store instructions • In chiller pack from 30 minutes after birth and transferred to fridge within 4 hours * Yes No More information is below More information about storage I can confirm that the person named above: Has confirmed with Midwife/GP that any medications I am taking are deemed safe with encapsulation Do not have any present viruses or infections Has not smoked during this pregnancy Name of Person completing this form * Phone Number of person completing this form * Submit