Placenta Encapsulation Service Agreement

Please read and initial the Placenta Encapsulation Service Agreement and fill out your Placenta Encapsulation Registration Form. Your due date will be reserved on my calendar once these forms have been completed and your $50 deposit--cash, check, or Paypal (located on our registration page) has been paid. If you'd prefer to have a printed version please email newearthrisingbirth@gmail.com and we'd be happy to send you a copy.

Please don't hesitate to email newearthrisingbirth@gmail.com or call (802) 343-1999 if you have any questions!

Please Initial Boxes Below

New Earth Rising will prepare your baby's placenta in capsule form for your own personal use. New Earth Rising also prepares mother’s broth and tinctures, prints, salves and body butters upon request. This service may be provided by an Independent Contractor. Client Responsibility It is your responsibility to notify me as soon as possible after the birth to make arrangements for transfer of your placenta to me. Failure to so may result in delayed placenta preparation and encapsulation and can cause decreased potency of nutrients, hormones and other beneficial attributes of the placenta. Improperly handled placentas are susceptible to spoilage and all placenta work is done at your own risk. Please ensure your placenta is kept fresh. It can remain at room temperature for 3-4 hours following the birth. After that it should be refrigerated or otherwise kept cool. If it is going to be more than 3 or 4 days before the placenta can be prepared it should be frozen. It is your responsibility to notify me if you test POSITIVE for Group B Strep (GBS), or if there's an infection present after delivery. Limitations and Disclaimer I am not a licensed medical professional and I am not able to diagnose, treat or prescribe for any health condition. Services and fees are for the preparation and encapsulation of your placenta, not for the sale of the pills. No specific benefits or effects are promised. Benefits will vary from person to person. Many of the ascribed benefits are well supported by evidence based research; but none have been evaluated or approved by the FDA.

As a condition of this service, you make the following assertions: You agree that… ● You are paying for the placenta encapsulation service only. ● There are risks involved with ingesting your placenta if you have smoked cigarettes 3 months prior to and/or at any time during the length of my pregnancy. ● Your care provider and you have determined (or will determine) that your placenta is healthy and suitable for encapsulation prior to the day of encapsulation. ● Your placenta will be handled in a manner appropriate for safe food preparation after birth (i.e. kept cold). Medical Contraindications I certify that I have never been diagnosed with and am not now afflicted with any of the following diseases: ● Hepatitis-B, -C ● HIV ● Hepatitis ● Syphilis ● You do not have active genital herpes Note: For your safety and the safety of others, if you have ever had any of the following bloodborne diseases, we will be unable to process your placenta.

You understand that… ● New Earth Rising. will prepare your baby's placenta in a capsule & broth, (and tincture, prints salves, belly butter for additional fees) for your personal use (and your baby) and that this service may be provided by an Independent Contractor. ● Your encapsulation cannot be completed until New Earth Rising. has received notice that you have read this Agreement and received your remaining payment in full. ● The Placenta Encapsulation Specialist (PES) views each placenta as a sacred connection between mother and child and will treat it accordingly. ● You will not hold the PES, New Earth Rising., and any of its employees or independent contractors responsible if your placenta is accidentally damaged during the encapsulation process. ● You must keep your placenta in your possession at all times and will not be refunded your deposit if you allow the hospital to “store” your placenta and/or if you lose your placenta. ● The PES does not determine whether your placenta should be consumed and makes no guarantee of your personal results from the capsules. ● The capsules should not be taken during times of illness, including times of infection (i.e. bacterial cold, flu, or mastitis). You understand that taking capsules can worsen these conditions or take you longer to recover from. Processing Methods Traditional Chinese Medicine (TCM) -- In this method, your placenta will be steamed with ginger and myrrh before dehydrating. This is to enhance its warming and healing properties. This method also kills any bacteria and reduces risk of spoilage. Mother’s Broth -- This broth comes from the steam water and contains nutrients and healing properties that are warming. Placenta Tincture -- 5-6 capsules worth of prepared placenta is covered with high quality 80 proof alcohol and then steeped for 6 weeks. The solids are drained off and the resulting tincture is shelf stable indefinitely. Placenta Salve -- Your own placenta powder is infused into a high quality salve base, with or without your choice of essential oils. The Salve base is made of: Organic shea butter, organic macadamia nut oil, organic coconut oil, organic beeswax, and vitamin E. You release New Earth Rising, and its representatives, agents, owners, employees, independent contractors from any and all liability for any effects you may experience after choosing to take/use your placenta capsules, broth, tincture, salves, belly butter, or prints. Full payment is due by 38 weeks. Personal checks will not be accepted at this time.. Refunds The $100 deposit is nonrefundable. If you choose to terminate this agreement after releasing your placenta to me, but before placenta preparations have begun, I will return your placenta to you but the $100 deposit will be retained. Once preparation of your placenta has begun, there will be no refund and payment in full ($400) will be due, even if you choose not to take the finished capsules.

Photo Release (Optional) I give permission to New Earth Rising (Ashley Bouffard) to photograph my placenta before during and after processing and use those photographs as she desires for marketing, advertising, educational or promotional reasons in print or on the internet.

Electronic Signature

Date

YYYY

Estimated Due Date

YYYY

Phone

(###)

###

####

Additional Notes