Book Now - Doula Fairy - Placenta Specialist

Full Name *

I am happy for Doula Fairy - Placenta Specialist to collect the following information to complete my booking and provide the service requested *

Yes

Mobile Number *

Email Address *

Birth Partners Name

Birth Partners Mobile Number

Home Address *

Estimated Due Date *

Where are you planning to birth?

Home

Birth Centre

Hospital

Other

Which hospital are you booked in with? (If your hospital is not listed please email me for details of courier charges) *

Where did you hear about Doula Fairy? *

Please confirm *

Please tick here to confirm that you have read the document ‘PRN Information Guide for Expectant Mothers'?'

Have you spoken to your midwife about your choice to encapsulate? *

Yes

Have you been diagnosed with Group B Strep in this pregnancy? *

Yes

Have you ever tested positive for AIDS, HIV, Hepatitis B, Hepatitis C or CJD? *

Yes

For the health and safety of yourself and your Specialist we MUST have an honest answer to the above question

Have you smoked regularly during pregnancy? *

Yes

For the health and safety of yourself we MUST have an honest answer to the above question

Have you been prescribed regular medication during your pregnancy? *

Yes

If YES, you must seek approval from your prescribing doctor before your booking can be accepted

Do you have any allergies? *

Yes

If YES, please note below

Which service do you require? *

I am happy for Carly Lewis to contact me in response to any questions I may have

Yes

Any other notes?

I am happy for Carly Lewis to send me a feedback form 6 weeks after birth

Yes

1. By completing this booking form, you are requesting the service (s) of a Placenta Remedies Provider (PRP) who is trained and insured to arrange or provide the placenta remedies chosen by you. 2. All placenta remedies are for your own personal use with the exception of the homeopathy made specifically for the baby. 3. The benefits reported from consuming the placenta are anecdotal and without scientific evidence we cannot claim that mothers will receive them. Benefits noted are based on research studies, article and testimonials. 4. Placenta Remedies Providers are unable to process placenta services if you have a current or previous diagnosis for HIV/AIDs, Hepatitis B and/or Hepatitis C, CJD. 5. To ensure safety for all, any equipment utilised in the process of providing placenta remedies to you are subject to current hygiene standards and regulations currently in place in the UK. Hand blenders used for placenta smoothies are ‘one use’ only unless agreed by Environmental Health and your PRP. 6. The placenta will be stored correctly in line with the guidance provided by your Placenta Remedies Provider, and those guidelines shared with your midwife or doctor when packaging the placenta for transport. The placenta will be placed into the collection kit or a fridge within 30 minutes of birthing, and you agree to ensure the placenta remains chilled until collection. 7. Please contact your Placenta Remedies Provider as soon as possible after birth, and within 12 hours to arrange collection. 8. Your Placenta Remedies Provider cannot be held accountable if the placenta is unavailable for processing due to loss or other reasons beyond influence. Should the situation be beyond control, only the booking deposit is retained. Any further payments which have been made will be refunded. 9. By ensuring that the chill chain has been completed fully by yourself, and following all necessary procedures and hygiene protocols, your PRP cannot be held responsible for any results or effects experienced before, during or after consuming the placenta. 10. Full payment is due upon completion of the placenta remedies. 11. By checking the box/signing below you agree that all the information you have given is correct and to the best of your knowledge. You also agree to the Terms and Conditions above and you have thoroughly read and will follow all the guidelines in the documents provided in your collection kit to ensure the safe storage of your placenta. *

I have read and understood the terms and conditions

If you are human, leave this field blank.