Placenta Encapsulation Contract
ADK DOULA
Waiver and Release
I understand in acknowledgement of placental practices, choosing to encapsulate my placenta is not intended to prevent or treat any physical or mental diseases, ailments or symptoms and that I am choosing to consume my placenta for my own personal beliefs, whether it be spiritual or cultural. I also acknowledge that there are no statewide or federal regulations preventing me from obtaining and encapsulating my placenta in my home.
I understand that the act of ingesting my placenta in any form has not been tested, nor approved by the FDA, and I ingest this at my own risk. I release EMILY GAUL/ADK DOULA and its representatives from any liability. I understand EMILY GAUL is not a medical professional and will not diagnose, treat or prescribe for any health condition.
I will provide EMILY GAUL/ADK DOULA with blood work documentation stating that I have been tested for STD’s and the results were negative. It is my responsibility to supply documentation regarding my STD status and inform the specialist of any known blood-borne illness or lack thereof (such as HIV, Hepatitis, etc.) by showing your specialist a copy of your most recent blood work. Any physical paperwork given to EMILY GAUL and ADK DOULA regarding health status will promptly be shredded or deleted within 24 hours of receiving or given back to the client, at their request.
If my Doctor, Midwife or Nurse recommends sending my placenta to pathology for testing, I will request that they take a sample of the placenta in the room instead of taking the entire placenta. Once a placenta is taken to pathology, there is a risk of contamination by chemicals, improper storage, or even a mix-up of placentas. If my placenta is taken to pathology, I understand that we cannot guarantee the safety. If you wish to continue your encapsulation at that point, you will be fully responsible for any negative outcome.
I understand that it is my responsibility to familiarize myself with the hospital or birthing center’s policies around storing and releasing the placenta. EMILY GAUL/ADK DOULA will do their best to pick up the placenta within a timely manner but cannot guarantee a pick-up within an hour. If placenta does need to leave the hospital within an hour, I am responsible for arranging storage.
I understand that my placenta has been handled and encapsulated by EMILY GAUL and she has been certified in proper sanitation and handling procedures. The placenta will be cleaned, dehydrated and put into pill form in a sanitary and sterile workspace. Upon receiving my placenta capsules and/or placenta tinctures from EMILY GAUL, I waive any and all rights to hold the specialist responsible for any undesired effect of consuming the capsules or tincture.
I do not hold EMILY GAUL and ADK DOULA responsible or liable for any transport mishap that is beyond their control (i.e. car accident), and understand that I am choosing to have the specialist encapsulate my placenta in their home. I put full trust that it is being handled in a sanitary and safe environment.
I understand that upon receiving the pills, EMILY GAUL and ADK DOULA is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules or tincture. I understand that since your placenta is specific to your own body, your specialist cannot determine how your body will react to consumption. If you experience any negative reactions, please discontinue use.
Services and fees are for the preparation and encapsulation of your placenta and not for the sale of the pills. I agree that upon completion of this agreement, I will put down a non-refundable full payment for services.
I give my permission to EMILY GAUL and ADK DOULA to photograph my placenta before, during, and after processing and use those photographs for marketing, advertising, educational and/or promotional reasons in print, on the internet, and on social media. I understand that no personal information will be associated with these photographs.
By digitally signing below, I acknowledge and agree to all the above terms.
