Placenta Service Waiver & Release of Liability Form

I, (name entered on bottom line) hereinafter referred to as “I” or “Client,” give fully informed consent and permission for Aspen Roots Midwifery, LLC, a Colorado limited liability company, hereinafter collectively referred to as “you” or “Doula,” or "midwife" to provide placenta services to me. This waiver is not with Heidi Hennigan personally. *

I agree

I understand and acknowledge that in accordance with Colorado Law, there are no statewide laws, rules, or regulations preventing me from directing the disposition of my placenta or preventing my Doula/midwife from obtaining and encapsulating my placenta at my request. I also understand and acknowledge that choosing to encapsulate my placenta, whether in pill or tincture, is not intended to prevent or treat any physical or mental diseases, ailments, or symptoms, that my Doula is making no representations as to such, and that I am choosing to consume my placenta for my own personal beliefs and at my own risk. *

I agree

In addition, I acknowledge that I have fully researched placenta encapsulation and consumption, and I fully understand the benefits and risks of such. I understand that my placenta will be handled and encapsulated or put into tincture form according to OSHA and Colorado food safety and handling standards, and will be cleaned, cooked, dehydrated, and put into capsule or tincture form in a sanitary workspace, whether in my home or another location of my Doula’s choosing. Further, I acknowledge and agree that my Doula has not represented to me that any particular outcome is promised or guaranteed. *

I agree

Further, I have provided my Doula/midwife with true and correct copies of blood documentation stating that I have been tested for sexually transmitted diseases and other blood borne disease, and the results were negative. Should my Doula/midwife not request such records or should I fail to provide such records, this has no bearing whatsoever on the enforceability of this Waiver and Release of Liability, and is not intended in any manner to be a waiver by my Doula of any rights or protection afforded my Doula/midwife by this Waiver and Release of Liability. *

I agree

Now, therefore, with full and informed consent, I hereby WAIVE ANY AND ALL RIGHTS to hold the Doula/midwife responsible for any undesired effect relating to the services contemplated hereunder. *

I agree

In addition, I, on behalf of myself and my heirs, administrators, personal representatives, executors, and assigns, hereby RELEASE AND FOREVER DISCHARGE my Doula from all damages or causes of actions, either at law or in equity, which I may have or acquire, or which may accrue to me or my heirs, administrators, personal representatives, executors, or assigns, as a result of consuming my placenta or as a result of any services contemplated hereunder. I intend this to be a COMPLETE RELEASE AND DISCHARGE as to my Doula from any and all liability whatsoever. *

I agree

I acknowledge and agree I have read all statements contained herein and I fully realize that I am signing a COMPLETE RELEASE AND BAR to any claims which I have or believe I have resulting from the services contemplated hereunder. *

I agree

I further acknowledge and agree that this Waiver and Release of Liability constitutes the entire understanding between the parties relating to this subject matter and supersedes all prior or simultaneous representations, discussions, negotiations, and agreements, whether written or oral.kbox 7 *

I agree

By entering my name below and hitting submit, I acknowledge this as a binding document *

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