Placenta Encapsulation Registration

Sign me up for postpartum bliss...

Name *
Phone *
Address *
What is your Due Date?
The undersigned agree to save Mother Chi Birthing® and Betsy Huljev harmless from any and all liability, liens, claims, demands, damages, expenses, fees, costs, fines, penalties, suits, proceedings, actions and causes of action of any and every kind and nature arising or growing out of or in any way connected with participation in the PLACENTA ENCAPSULATION process and consumption of placenta pills. Betsy Huljev does not give medical advice and I agree to consult a doctor or midwife before making any medical decisions in regards to any bodily issues. I agree to stop the consumption of placenta pills should a fever set in or infection take residence in my body. Please call Betsy at (919) 630-6784 with any questions concerning the encapsulation process. A $50 deposit (non-refundable) payable to Betsy Huljev is needed to complete your registration, and the remainder of the encapsulation fee ($200) is due upon final presentation of capsules. The PLACENTA ENCAPSULATION fee ($250) covers time, travel (within 10 miles of Mother Chi Birthing), all necessary materials for encapsulation, tincture, placenta prints, & cord wrapping. There is an additional travel surcharge of $25 for travel 10-30 miles away from Mother Chi Birthing or 3112 Umstead Road, Durham NC, 27712. The total for encapsulation plus travel surcharge will be $275. Additional travel surcharges are as follows: 30-50 miles away + $50 ($300 total), additional $25 per 10 miles beyond 50+ miles away.
Please type YES or NO in this space.
Today's Date *
Today's Date
Placenta Encapsulation Services Agreement: I have asked Betsy Huljev of Mother Chi Birthing (Placenta Encapsulation Specialist [PES]) to encapsulate my baby’s placenta in capsule form for my own personal use. As a condition of this service, I make the following assertions: I agree that…I am paying for the encapsulation service only. My placenta does not contain any transmittable diseases such as Hepatitis-B, -C or HIV/AIDS. My care provider and I have determined that my placenta is healthy and suitable for encapsulation. The placenta has been handled in a manner appropriate for safe food preparation since the birth. I understand that…The PES views each placenta as a sacred connection between mother and child and will treat it accordingly. I will not hold the PES responsible if my placenta is accidentally damaged during the encapsulation process. The PES does not determine whether my placenta should be consumed and makes no guarantee of my personal results from the capsules. The capsules should not be taken during times of illness, such as the common cold, flu, or mastitis. I understand that taking the capsules can make these conditions worsen. The PES will release a copy of this document to be kept on record at the main office of Placenta Benefits Ltd. in North Las Vegas, NV. I release Placenta Benefits Ltd., Jodi Selander and the PES (if other) from any and all liability for any effects I may experience after choosing to take the capsules. © Copyright 2008-2014 Placenta Benefits Ltd.
Today's Date *
Today's Date