Placenta Encapsulation Agreement

The Well Birth Services Placenta Encapsulation Agreement

📍 www.birthingwelldoulaagency.com

📧 thewellbirthservices@gmail.com | 📞 (423) 280-6070
Service Details & Fees

I, the undersigned client, request the placenta encapsulation services provided by The Well Birth Services, which includes:
✅ Placenta Encapsulation

✅ Umbilical Cord Keepsake

✅ Placenta Print

💲 Total Cost: $300 (due at time of booking payment via Venmo)

Optional Add-Ons (check all that apply):

☐ Placenta Tincture ($30)

☐ Placenta Salve ($25)

Service Area & Transportation

• I serve within a 20-minute radius of East Brainerd, Chattanooga, TN.

• If you are outside of this radius, you may:

▫️ Drop your placenta off in East Brainerd

▫️ OR overnight ship it in a properly insulated, cold-packed container (address provided upon request).

• Return shipping cost will be included once the process is complete and weighed

Placenta Handling & Storage Instructions

To protect the safety and quality of your placenta:

1. Label the placenta with your full name and date of birth.

2. Double-bag in food-safe bags.

3. Place in a cooler with ice packed in sandwich size ziploc bags around the bagged placenta, then refrigerate (within 2 hours of birth), or freeze if delay is anticipated.

4. I only pick up during daylight hours (7AM–7PM). If you deliver overnight, proper storage is your responsibility.

5. If refrigerated: deliver/pickup within 3 days.

6. If frozen: deliver/pickup within 6 months.

🚫 Improper package or storage will result in the placenta being ineligible for encapsulation. No refunds will be issued for unsafe placentas.

Disclaimers

• I understand that placenta encapsulation is not FDA-approved, and no medical claims are made by The Well Birth Services.

• The encapsulator is not a licensed medical provider for this service, cannot diagnose or treat any condition, and does not guarantee results.

• I understand and accept the risks associated with consuming placenta remedies.

• I understand it is my responsibility to ensure timely, proper packaging, handling, and delivery.

**There may be occasion where your placenta is unusable, in this case, you are agreeing to discuss what the circumstance is with the encapsulation prior to discarding. If you're unable to have a conversation in this regard your payment will be non refundable.

Shipping Guidelines (For Clients Outside the Radius)

📦 If shipping your placenta:

1. Freeze it immediately after birth.

2. Double-bag and place in an insulated shipping box with dry ice or cold packs.

3. Ship overnight to the provided address (must request address from number listed above)

4. Include your full name and contact information inside the package.

🛍️ Your finished capsules and keepsakes will be shipped back to you with tracking via USPS or UPS.

Consent & Agreement

By signing below, I confirm I have read, understood, and agreed to all the terms above. I release The Well Birth Services from any and all liability relating to placenta encapsulation and consumption.

The process that I use for encapsulation is the TCM method. This method is where your placenta is steamed at a high temp, dehydrated and ground into a powder then into capsules. There are other methods available but you must request.

If youd like extra supportive herbs added to your pills please notify when you order and when youre requesting pick up day of birth.

REFUNDS are given on a case by case basis and any supplies that have been pre purchased as well as a retainer for your spot must be deducted from refund if there is one being issued.

Your Name

First NameLast Name

Partners Name

First NameLast Name

If you have a doula please list their name and phone number below

Email

example@example.com

Pick up Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Drop off address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Partners Phone Number

Area CodePhone Number

Due Date

Date

If you have a name or gender for your baby please share (if youre comfortable) below: (sometimes we can create custom art with these details in mind)

Signature

My Products

Placenta Encapsulation, cord keepsake, placenta printEncapsulation is a part of every package and where able we can create a placenta print for you as well as an umbilical cord keepsake.

$300.00 Quantity

Add on Placenta SalvePlacenta Salve: Nourishing Healing for Skin & Beyond Our Placenta Salve is a deeply restorative, nutrient-rich balm designed to support healing and skin health from postpartum recovery through every stage of life. Infused with your placenta’s natural growth factors, stem cells, and anti-inflammatory properties, this soothing salve is blended with organic oils, herbs, and beeswax to create a powerful, all-purpose skin remedy. Postpartum Healing: • Helps soothe and repair perineal tears, C-section scars, and sore nipples • Aids in reducing inflammation and promoting tissue regeneration • Supports stretch mark healing and skin elasticity Long-Term Benefits: • Excellent for minor cuts, burns, and scrapes • Soothes dry, irritated skin and eczema flare-ups • Can be used on aging skin to support collagen production and elasticity Gentle yet effective, our Placenta Salve is a must-have for every mother’s natural healing toolkit. Apply as needed to support your body’s journey through motherhood and beyond.

$30.00 Quantity

Add on Placenta TincturePlacenta Tincture: A Lifelong Elixir for Hormonal Balance Our Placenta Tincture is a powerful, all-natural remedy designed to support mothers through every stage of life—from postpartum recovery to menopause. Made from your own placenta, this alcohol-based extract preserves the rich nutrients and hormones found in the placenta, offering long-term benefits for emotional well-being, energy levels, and hormonal balance. Postpartum Benefits: • Aids in emotional stability and reduces the risk of postpartum blues • Supports hormonal balance as your body transitions after birth • Helps replenish essential nutrients for recovery and energy Long-Term Support: • Can be used during times of stress, fatigue, or hormonal fluctuations • Supports menstrual cycle regulation and overall well-being • Helps ease the transition into menopause by providing natural hormonal support Because the tincture is shelf-stable, it can be used for years to come, making it a valuable addition to your holistic wellness routine. Just a few drops under the tongue or in a small amount of water can help you feel grounded, balanced, and supported at every stage of motherhood and beyond.

$25.00 Quantity

Total

$0.00

Today's Date

Please list any details of current medical conditions, medications you're currently taking, sexually transmitted or communicable diseases.

Venmo is preferred payment method — due to the set up of this platform there is PayPal also listed. Please consider using Venmo as paypal takes fees when sent this way.