BOOKING REQUEST Please fill in the booking form and complete the consent section to arrange your service. By completing this form, you consent to Nestle & Bloom’s Service Terms & Conditions. Name Email Phone number Home Address Estimated Due Date Collection Hospital Gold Coast University Hospital Gold Coast Birth Centre Greenslopes Private Hospital Home Birth Logan Hospital Mater Public Mothers Hospital Mater Private Mothers Hospital Mater Private Hospital Redlands North West Private Hospital Redlands Hospital Royal Brisbane and Womens' Hospital Royal Brisbane Birth Centre St Andrews Ipswich Private Hospital Wesley Maternity Unit Other Do you have a birth support person we should contact to arrange placenta collection? (If yes, please provide name and contact details) Does your doctor/midwife support your decision to encapsulate your placenta? Yes No How many times have you birthed? Never Once Twice Three Births Four Births Five Births or more Is this a twin pregnancy? (Please note extra charges may apply for twin placentas) Yes No Are you having a caesarean or induced birth? (If yes, your delivery date is fixed, rather than an "estimated due date") Yes No Do you consent for photos to be taken throughout the process of your placenta encapsulation? Yes No Would you like Nestle & Bloom to email or text you photos of your placenta? Yes No Have you ever tested positive for HIV/AIDS, Hepatitis A, B, or C, or Syphillis? Yes No Are you aware of any other bloodborne diseases that you are a carrier for? (Please provide details) Have you ever tested positive for GBS? Yes No Where did you hear about Nestle & Bloom? Facebook Gumtree Past Client Friend or Family Midwife/doctor Google Placenta Services Directory Other Please select you service (If there is a special, these prices will be changed in the invoice) TCM Method Encapsulation ($280)Raw Method Encapsulation ($260)Half Raw/Half TCM Method Encapsulation ($300)TCM Method Powder Only ($230)Raw Method Powder Only ($220)Half Raw/Half TCM Method Powder Only ($270)Frozen Placenta Gems ($180)Placenta Salve 120ml ($60)Placenta Tincture 100ml ($60) Would you like a complementary cord keepsake? Yes No I consent that all the above information is accurate and true. If for any reason the above information changes, I will notify Natalie Johanik via email or phone as soon as practicable, and before collection of my placenta. I consent Today's Date REQUEST BOOKING