Placenta Process Record – Client Information

PRN Member email address (your form will be sent to this address) *

Client's name *

Email address (if permission has been given for further contact on the Booking Form)

Date *

Documents provided to Client (tick all that apply) *

Have you received a completed and signed Placenta Release Form *

Yes

No, why?No, why?

Placenta was transported back to Specialist's work space in *

Chiller pack provided by Specialist to client

Chiller pack provided by client

Chiller pack with fresh ice blocks bought to collection by Specialist

Other, how?Other, how?

If the placenta is not going to be processed immediately how has it been stored?

Chiller pack with fresh ice blocks

Dedicated placenta fridge

Kitchen fridge (placed safely on bottom shelf)

Freezer, why?Freezer, why?

Other, how?Other, how?

If the placenta is to be temporarily stored in the fridge, at what temperature is the fridge holding food at?

Time of temperature recording

Temperature of placenta on arrival at work space or prior to storage (if not under 8°c make a note in "Corrective action taken" box below) *

Time of temperature recording *

If the placenta had to be frozen due to swabs taken at birth, please note the outcome, date and recommended remedies

Date & time frozen placenta has been removed from the freezer and placed in fridge to defrost

Corrective action taken

Notes