Placenta Encapsulation Intake Form

Client Details:
Full Name*

First NameLast Name
Estimated Due Date*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Partner's Name, if applicable

First NameLast Name
Partner's Phone Number
Please enter a valid phone number.
Where do you plan to give birth?*
Who is your Care Provider?*
Please list any allergies:*
Build your package:*

Placenta Encapsulation - $250Placenta tincture (2 oz) - $24Placenta tincture (4 oz) - $45Placenta Print - $35Placenta Print with color - $50
*** A travel fee based on the current IRS mileage rate will be calculated based on your birthing location and added to your service fee total.
Method of payment: *
I accept cash, Venmo, and Cashapp. Please contact me at (540)419-7903 or email jessica.shupe1@gmail.com if you need to discuss alternatives.
Client Responsibilities

Placenta encapsulation will be provided to you by Jessi Robinson, a certified Postpartum Placenta Specialist at the rate indicated in this contract. The fee is payable in full at the signing of this contract or at the time the placenta is picked up for processing. *Services will not begin if payment has not been received.

Client is to make arrangements in advance with the birth facility for release of the placenta. Please contact me if you require assistance or direction with this process.

Client will properly package and store the placenta for transport. The placenta will be double-bagged in gallon sized freezer bags and kept cool either in a refrigerator or on ice. If it is not possible for the encapsulation process to begin within 72 hours after birth, keep the double-bagged placenta in the freezer. *If frozen, the placenta is to be defrosted in the refrigerator for 24 hours prior to preparation.

Please notify the specialist within 12 hours of birth to make arrangements for service to begin.
Please initial to indicate that you have read and understand the Client Responsibilities.
Process
- Your encapsulated placenta will take two consecutive days to prepare. This preparation will take place in the specialist's home unless another arrangement is discussed.
- Day 1 will consist of steaming the placenta, slicing it, and placing it in the dehydrator. The placenta will need to remain in the dehydrator for approximately 24 hours.
- Day 2 will consist of grinding the dehydrated placenta into powder and placing it in capsules for consumption.
- You will receive usage suggestions with your completed placenta capsules. The Postpartum Placenta Specialist will answer any questions that you may have.
- An average-sized placenta will generally yield between 75-200 capsules. The number of capsules varies due to the unique size of every placenta.
Please initial to indicate that you have read and understand the Process.
Limitations and Disclaimer

The benefits of ingesting your placenta have not been evaluated by the Food and Drug Administration. Your placenta is intended for ingestion only by the person that gave birth to it. There is no guarantee that the ingestion of your placenta capsules will yield the desired results.

The client takes full responsibility for their health and the use of the encapsulated placenta.
- I understand that no guarantee of results is either offered or implied.
- I understand that my Postpartum Placenta Specialist is not a medical professional and cannot diagnose or treat illness.
- I understand that general guidelines for placenta capsule usage are provided for reference only and I trust my own ability to follow my body for actual usage directions.
- I ascertain that I have no blood-borne diseases that have not been disclosed in writing to my Postpartum Placenta Specialist.
- I release my Postpartum Placenta Specialist from any and all liability resulting from the consumption of my placenta.
- Equipment failure is beyond the control of the Postpartum Placenta Specialist.
- I understand that no refunds will be issued in the event that we choose not to utilize the Postpartum Placenta Encapsulation service.
Please initial to indicate that you have read and understand the Limitations and Disclaimer.
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