Placenta Medicine Form

Full Name

Email *

Phone Number *

Address

Street Address *

City *

State *

Country *

Postal code *

Date of Baby’s Birth *

What is Baby’s Gender? *

What is their name? *

Where was your birth (hospital/home/etc)? *

Details of your birth *

Vaginal

Instrumental

In labour cesarean

Prelabour cesarean

If other, please list details here

Were you on any medications during pregnancy? Please list. *

Was there any meconium present during labour? *

Yes

No

Unsure

You will be contacted to arrange a date and time for your appointment.

Please complete the questions below that are relevant to you so we can best prepare for our time together.

Placenta Storage Details

How has the placenta been stored since birth? *

Was it refrigerated within 48 hours of birth? *

Yes

No

Was your placenta sent away for histology testing? *

Yes

No

Health Considerations

Do you have any known blood-borne viruses (e.g. Hepatitis B/C or HIV *

Yes

No

Were you diagnosed with any active sexually transmitted infections during pregnancy? *

Yes

No

Did you have any active herpes simplex virus (HSV) outbreaks during pregnancy or birth? *

Yes

No

What products are you interested in?

Medicines

Dehydrated Placenta (Jerky Style)

Powdered Dehydrated Placenta

Encapsulated Powdered Placenta

Chocolates with Powdered Placenta

Amniotic band aids for perineal/cesarean or skin trauma and burn healing

3x Tinctures (Chronic, Acute & Immune Booster)

Dried umbilical cord for medicinal infusions for child

Powdered Placenta Balm for Mother

Dried Amniotic Membrane Balm for Baby

Acknowledgement of Placenta Medicine

Placenta medicine is a sacred tradition passed down through many generations and cultures around the world. It is believed to support postpartum recovery, replenish iron levels, balance hormones, increase milk supply, and support overall emotional and physical wellbeing. Many mothers report feeling more grounded, nourished, and emotionally resilient after consuming or working with their placenta.

However, these benefits are anecdotal and not supported by conclusive scientific studies. The use of placenta remedies is not regulated by any official health body in Australia.

By submitting this form, you acknowledge that:

You understand the potential risks and benefits of placenta medicine are not clinically proven.
You take full responsibility for your decision to ingest or use your placenta.

I (Sarah Smits) offer this as a traditional and ceremonial service, and cannot be held liable for any adverse outcomes that may arise.

I have read and understand the above information and accept full responsibility for my use of placenta medicine. *

I agree