PLACENTA ENCAPSULATION AGREEMENT AND RELEASE OF LIABILITY

I understand that in acknowledgement of placental practices, choosing to encapsulate my placenta is not intended to prevent or treat any physical or mental diseases, ailments or symptoms and that I am choosing to consume my placenta for my own personal beliefs, whether it be spiritual or cultural.

I understand that the act of ingesting my placenta in any form has not been tested, nor approved but the FDA, and I ingest this at my own risk. Upon receiving my placenta capsules from Vitality Home Birth, I waive any and all rights to hold the specialist responsible for any undesired effect of consuming the capsules. Furthermore, I release Alison Fischman, CPM, LM, Heidi Riendeau, CPM, LM, Hannah Spark, and Vitality Home Birth, PLLC and its representatives from any liability.

I understand that my placenta has been handled and encapsulated according to OSHA and Vermont Food Safety and Handling standards, and has been cleaned, steamed, dehydrated and put into pill form in a sanitary and sterile work space.

I do not hold Alison Fischman, CPM, LM, Heidi Riendeau, CPM, LM, Hannah Spark nor Vitality Home Birth, PLLC responsible or liable for any transport mishap that is beyond their control (ex. car accident or detainment), and understand that I am choosing to have the specialist encapsulate my placenta in my specialist’s home. Services and fees are for the preparation and encapsulation of my placenta and not for the treatment of a condition or the sale of the pills.

I recognize that it is my responsibility to supply documentation regarding my GBS, STD or any other potential infection status. I understand that upon receiving the pills, Alison Fischman, CPM, LM, Heidi Riendeau, CPM, LM, Hannah Spark, and Vitality Home Birth, PLLC is no longer liable including but not limited to any other person(s) ingesting my own placenta capsules.

Upon checking the box for YES “I have read and understand the Vitality Home Birth PLACENTA ENCAPSULATION AGREEMENT AND RELEASE OF LIABILITY” on my inquiry form, I hereby release, wave, discharge and covenant not to sue Vitality Home Birth, PLLC and its associates.