Placenta Encapsulation Order Form

Your Name*

First NameLast Name

Phone Number*

Area CodePhone Number

secondary contact of partner/support person*

Area CodePhone Number

Your E-mail*

Have you been diagnosed with Group B Strep ( GBS) ?*

YesNoI have not been tested

Have you been diagnosed with preeclampsia?*

NoYesI have not been tested

Do you have any health conditions such as blood born illnesses or Sexually transmitted diseases that we should be aware as we take care of your placenta? If yes, please explain in detail.

My Products

Placenta Capsules/pills$250.00

*how many capsules I produce depends on the size of your placenta. All orders are delivered to your desired location for convenience.

Placenta Tincture$25.00

This Item is an Add on only to The Placenta Capsules and will be delivered in 6 weeks time. 4oz Placenta tincture

Total $0.00

Estimated Due Date*

MonthDayYear

Type of birthing facility*

Name of facility:*

Physical Address of birthing facility for pickup*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Where Can we Drop off your Order after birth? Please provide Address.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Please read! Placenta Encapsulation Contract “Placenta encapsulation is the act of taking a fresh placenta steaming or slicing the placenta raw, dehydrating, grinding and putting the placenta powder into consumable capsules. All processes are done with respect of that placenta and in a sanitary environment. P.S. Love Mommy Doula Services LLC adheres to strict OSHA guidelines and follows proper food safety standards. The placenta capsules that are being prepared are for your (owner of the placenta) consumption only and are not designed to reverse medical conditions or ailments from pregnancy, to treat postpartum depression, to ensure normal milk supply or to replace medical attention. P.S. Love Mommy Doula Services LLC are NOT licensed medical professionals such as a care provider or physician and P.S. Love Mommy Doula Services LLC is not able to diagnose, treat or prescribe for any health condition. All fees are for the service of encapsulating your placenta, not for the sale of the capsules. Each woman will react to her placenta capsules in different ways. Some of the ascribed benefits of placenta consumption are supported by ongoing research, however these benefits have not been evaluated or approved by the United States government or the Food and Drug administration. It is your responsibility to determine whether using placenta capsules can be beneficial to your wellbeing postpartum.

Client Responsibility: It is your responsibility to notify P.S. Love Mommy Doula Services LLC within 24 hours of the birth so that we can work together to make arrangements. (please give extra consideration to major holidays) Failure to do so may result in delayed placenta preparation and encapsulation and may cause decreased potency of nutrients, hormones, and other beneficial attributes of the placenta. Improper storage of the placenta may result in spoilage. It is your responsibility to discuss release of your placenta from the facility where you will give birth during the prenatal period and to ensure proper storage of your placenta in a refrigerator or cooler with ice. It is also your responsibility to inform P.S. Love Mommy Doula Services LLC any known blood borne illness (es) or other health issues (such as HIV, hepatitis, MRSA, etc.) that could place P.S. Love Mommy Doula Services LLC or any others who may come in contact with your bodily fluids (specifically maternal and fetal blood as well as amniotic fluid) at risk. Some specific sexually transmitted diseases such as Hepatitis, herpes or HIV may preclude P.S. Love Mommy Doula Services LLC from offering placenta encapsulation. P.S. Love Mommy Doula Services LLC Responsibility Include maintaining client confidentiality, committing to completing the encapsulation process within 72 hours of starting (usually within 36-48 hours), and upholding the highest standards of cleanliness, safety, and quality of professional placenta preparation services. It is important to understand that there may be circumstances in which your placenta cannot be used. Significant abnormalities of the placenta may necessitate your doctor or midwife sending your placenta to Pathology for further examination. Once the placenta has been released to Pathology, P.S. Love Mommy Doula Services LLC will not be able to encapsulate it without an additional waiver. Other conditions, such as signs of infection in the mother during labor, may mean that consuming your placenta could be harmful to your health. P.S. Love Mommy Doula Services LLC will always consult with you prior to making a choice on whether or not your placenta is viable for ingestion. It should be possible to claim your placenta after Cesarean surgery. It is important that you let P.S. Love Mommy Doula Services LLC know if you have any health concerns or conditions which may affect the health of your placenta or the health and safety of anyone who may come into contact with your placenta. Refunds: In the event your placenta is unavailable to you (ex. sent to Pathology and not released) or if your placenta has been contaminated with a bacterial infection and therefore will not be safe to encapsulate we will be happy to offer a partial refund of $100. However once your placenta has been picked up. You will not be entitled to a refund however if the placenta is unable to be consumed- we will offer a placenta print/art and cord keepsake.

My info:

Name: Latisa R.
phone: 310-927-9901

I have read, understood, and agreed to the above information. I accept the responsibility of gaining possession of my placenta, and notifying my placenta specialist within 24 hours of my birth. I understand the importance of appropriate handling and storage of the placenta. By signing below I authorize P.S. Love Mommy Doula Services to prepare my placenta for my own personal use.

Client Signature*