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Release of Placenta and Waiver of Liability

_________________ (name of mother)hereby instructs _________________________
(medical facility)to release Mother’s placenta produced at the birth of Mother’s child or in the case of multiples, children (the “Placenta”) on or about __________________ (approximate due date),into the custody of Mother or Mother’s designated representative.

Mother understands that certain medical conditions, known or unknown at the present time and which may be discovered during the birth process, may preclude release of the placenta due to the Medical Facility or its designated representative’s need for testing, or other purposes, on the placenta. Barring a demonstrated medical need to retain said placenta, Mother hereby authorizes the Medical Facility to release said placenta to the Mother or her representative(s) within twelve (12) hours of its birth.

Mother acknowledges that the Medical Facility makes no representations about the health or viability of the placenta. Mother expressly agrees to hold Medical Facility and its representatives harmless with respect to the release of the placenta and for any such subsequent purpose or use of the placenta. If the Medical Facility retains the placenta for any period of time, Mother requires that the Medical Facility store the placenta in a manner that retains its freshness and release it to Mother in such a manner.

Upon release to Mother, the Medical Facility will be absolved of all responsibility for the placenta.

_________________ ___________ Mother Date

_________________ ___________ Medical Facility Date