Placenta Application

Name *

First Name

Last Name

Date of Birth (please take note of calendar format) *

MM

DD

YYYY

Birth partner name *

First Name

Last Name

Baby's due date (please take note of calendar format) *

MM

DD

YYYY

Please tick the placenta remedy you require *

**Please note there is a $50 surcharge for twins for placenta encapsulation.

Placenta Encapsulation $350

Berry flavoured capsules $5 extra

Terms and conditions *

I am aware Kilter reserves the right to refuse services based solely on their professional opinion of the situation.

I take full responsibility of my own health and for researching and using the remedies provided. I understand Kilter does not give any warranty or representation that benefits are guaranteed and does not take responsibility for any results or effects I may experience before, during or after consuming remedies.

I am not carrying any transmittable diseases such as Hepatitis B, C, Syphilis or HIV/AIDs.

I understand that placenta remedies are recommended for my use only.

I am aware of Kilter’s placenta storage guidelines and will ensure they are followed. Failure to do so may result in spoilage of the placenta which would render it unusable for remedies.

I am aware Kilter will not share private information of mine with third parties and will only keep and securely store my information for as long as legally required.

In the event that my placenta is unavailable to me, ie. sent to pathology and not released by the hospital, any fees paid will be refunded in full, less a $50 administration fee.

I understand there is no refund for change of mind