New Orleans Placenta Services

Client Name Client Name First Last
Partner Name (If Applicable) Partner Name (If Applicable) First Last
Estimated Due Date or Baby's Birth Date Estimated Due Date or Baby's Birth Date / MM / DD YYYY
Place of Birth
Email
Are you using a Nola Nesting Doula? Who's your doula?
Address
(Please provide the best address for delivery of your placenta pills and/or kit) Address
(Please provide the best address for delivery of your placenta pills and/or kit)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Secondary Phone Secondary Phone - ### - ### ####
Allergies
Please select any of the following you are sensitive or allergic to.

Please select any of the following you are sensitive or allergic to. Latex Bleach Ginger Lemon Peppers Herbs Any other allergies Any other allergies
How did you hear about us?
Have a Happy Postpartum
Choose your encapsulation package. (All choice include a complimentary transport kit)

Choose your encapsulation package. (All choice include a complimentary transport kit) Be Happy - $300 (Placenta Pills, Pickup via Medical Courier, Delivery) Happy and Breastfeeding - $500 (Be Happy plus a breastfeeding course and a postpartum lactation visit with an IBCLC)
Be Happier

Be Happier Placenta Tincture - $30 Healing Placenta Salve - $30 Placenta Print - $30 The Whole Bundle (Tincture, Salve, Print) - $80
What type of capsule do you prefer?

What type of capsule do you prefer? gelatin capsules vegan capsules - $5
I would like my included breastfeeding class

I would like my included breastfeeding class in person online with one year of access included
I would like my services to be provided

I would like my services to be provided at Nola Nesting's Professional Placenta Kitchen In my home
When choosing in home encapsulation, I understand that Nola Nesting and it's subcontractors cannot guarantee a clean, pet-free space and I, the client, am responsible for keeping my placenta properly refrigerated at all times. A medical courier will not be picking up my placenta.

When choosing in home encapsulation, I understand that Nola Nesting and it's subcontractors cannot guarantee a clean, pet-free space and I, the client, am responsible for keeping my placenta properly refrigerated at all times. A medical courier will not be picking up my placenta. I understand the above statement and accept responsiblity
Would you like a cord keepsake included? (This is a gift to you, there is no charge)

Would you like a cord keepsake included? (This is a gift to you, there is no charge) yes, please include no, please do not include
We sometimes take photos of placentas for record keeping or education. Identifying information is never shared. Do you give permission for photos of your placenta to be used as described?

We sometimes take photos of placentas for record keeping or education. Identifying information is never shared. Do you give permission for photos of your placenta to be used as described? yes no
Nola Nesting Doula Client Code (Add a tincture to your cart and enter your coupon code. The tincture is our gift to you.)
Please read and sign below.
CLIENT RESPONSIBILITIES
It is the client’s responsibility to notify Nola Nesting as soon as possible after the birth of your baby so that we may schedule medical courier pickup and your services. Failure to do this can result in placenta deterioration and/or spoilage which may decrease the potential nutrients, hormones and other benefits, or render your placenta unusable for the purposes of encapsulation.

It is the client’s responsibility to discuss and secure release of the placenta with your medical care team and birth facility prior to labor/birth.

It is the client’s responsibility to inform Nola Nesting and/or your placenta specialist of any medical information (blood -borne illnesses, viral and bacterial infections, HIV/AIDS, Hepatitis, STDs, etc) that are contagious by contact with blood or other bodily fluids, such as amniotic fluid.

DISCLAIMER
Nola Nesting and its subcontractors are not a pharmacy, pharmaceutical representative, holistic practitioner, herbalist, or medical doctor and are therefore unable to diagnose, treat, or prescribe for any health condition. Benefits of placentophagy are supported by anecdotal evidence and there is research underway, but this has not been evaluated by the FDA. Services and fees are for the preparation and encapsulation of your placenta, not for sale of the pills. Placentophagy, (as it pertains to this contract agreement, is for supplementation and is intended only for ingestion by the mother who birthed the placenta and not for her family members, friends, or other individuals), is a natural nutritional supplement and as such cannot be promised or guaranteed to produce specific results. Placenta tinctures are made with alcohol and are not to be provided to children. Families who choose to utilize the services take full responsibility of their own health and for researching and using the remedies and understand Nola Nesting makes no claims of medical treatment.

PAYMENT POLICY
All services are nonrefundable once we have possession of your placenta. If you cancel services prior to Nola Nesting having possession of your placenta, your payment will be refunded, minus a $75 fee.
By signing below I (client) agree to the terms listed above.

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Name Name First Last
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Total

+Tax 3%

New Orleans Placenta Services

New Orleans Placenta Services

Allergies

Have a Happy Postpartum

Please read and sign below.

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Total

+Tax 3%

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