Placenta Encapsulation Request
And consent form
Your Name
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First Name
Last Name
Partner's Name
First Name
Last Name
Address
Street Address
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City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
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Area Code
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Due Date
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Day
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Month
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Do you have a history of any of the following?
Hepatitis B
Hepatitis C
HIV
STI's
Latex allergy (please explain)
Food allergy (please explain)
Other
What service would you like?
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Please Select
TCM Method- $240
TCM Method+Cord Keepsake- $265
Modified TCM Method- $250
Raw Method- $270
Raw Method+Cord Keepsake- $295
Half&Half Method- $280
Half&Half Method+Cord Keepsake- $300
Placenta Print- $30
Cord Keepsake- $35
Please read the following and sign
Placenta encapsulation is the process of preparing the mother’s placenta after the birth of her baby(ies). This involves separating the membranes and umbilical cord from the placenta, rinsing and draining maternal and fetal blood, steaming (or not, if raw), dehydrating and pulverizing to place into capsules. The ingestion of the placenta is known as “placentophagy.”The purpose of placentophagy by the mother is to reintroduce the beneficial vitamins, minerals, hormones, proteins, and other nutrients to her body following labour and birth to help restore a more balanced body function, prevent “baby blues” and postpartum depression, increase breast-milk production, shorten healing time, increase maternal energy levels, and provide an overall feeling of wellness to aid in the transition between pregnancy and the early postpartum period in the woman who has just given birth.
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by checking this box I understand and accept this statement.
Always speak to your care provider regarding any questions about your health, safety and wellbeing. Placenta services are not meant to be a replacement for medical advice or prescription medicines. If you are experiencing symptoms of postpartum depression, low milk supply, or other medical concerns please speak to your midwife or doctor.
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by checking this box I understand and accept this statement.
It is the client’s responsibility to notify me within 24 hours of birth to request pick-up or drop off of the placenta(s).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(s), and even spoilage of the placenta(s) which would render it unusable for encapsulation.It is also the client’s responsibility to discuss release of her placenta(s) after her birth from the establishment where she births and to ensure proper storage of her placenta(s) in a refrigerator or cooler. Your placenta must not be treated with alcohol, formalin, or any other preservative.
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by checking this box I understand and accept this statement.
Your placenta may be kept at room temperature for up to 2 hours. After that it should be refrigerated or otherwise kept cool. If it is going to be more than 3 or 4 days before the placenta can be prepared it should be frozen. A frozen placenta may require an extra one or two days of preparation time to allow for gentle thawing.It is important to note that there may be circumstances under which your placenta can not be used. Significant abnormalities of the placenta may necessitate your doctor or midwife sending your placenta to Pathology for further examination (rendering it unusable). Other conditions, such as signs of infection during labour, may mean that consuming your placenta will not be beneficial to you. If in doubt, we will consult with you before proceeding.Please let us know if you have any health concerns which may affect the health of your placenta or the health and safety of anyone who may come into contact with your placenta.
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by checking this box I understand and accept this statement.
It may not be possible for myself to encapsulate your placenta due to other commitments/concerns. This will be discussed with you after receiving this document and analysing your needs. There may be times when I am unavailable to collect your placenta for a few days. This possibility will be discussed with you when signing up. I will provide you with instructions on how to best store your placenta until I can collect it. In rare circumstances, I may not be able to encapsulate your placenta and every effort will be taken to make alternate arrangements.
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by checking this box you understand that in special circumstances, there may be a delay in encapsulating your placenta OR I may not be able to encapsulate at all.
From time to time I like to take photographs of placentas, capsules or cord keepsakes for educational purposes or for examples for other clients. These photos are shared without any identifying information other than information that may be relevant to the situation (such as "35 weeks" or "twin placentas"). Do you agree to photo release?
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YES
NO
Signature
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