Organically You Placenta Client Intake

Organically You Placenta
Client Intake Form
Name*

First NameLast Name
Estimated Due Date*

MonthDayYear
Date
Order Delivery Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Where do you plan on delivering your baby?*
Are you having a boy, girl or is it a surprise?*
Please indicate gender if known
Emergency Contact Phone Number*
Please enter a valid phone number.
Have you ever served in the U.S. Military?
Are you a birth worker or do you work in Women's Healthcare?
Yes, please explain or No
How did you hear about us?*

FacebookThe Birth Center of MidlandInstagramBrochuresReferralMy DoulaGoogle SearchOther

Which Services are you interested in?*

	Yes	Remarks
Placenta Powder Only (Honor Package)
Placenta Capsules
11x14 Watercolor Placenta Print
Cord Keepsake Gold
Cord Keepsake Natural
Raw or Dehydrated Placenta Tincture for Hormone Balance Gluten Free/Grain Free- Potato Vodka- GBS Negative only
Raw or Dehydrated Placenta Tincture for Hormone Balance-Whiskey
Dehydrated Placenta Skin Salve (healing ointment)
Raw Placenta Salve with Stem Cells (best for Cesarean Moms) GBS Negative only
Baby book Polaroid of your Placenta $5 3"x2"

If you chose a placenta print, what two colors do you want it be made in?*
Please type 2 colors or N/A
Are you okay with the plants & oils used in Traditional Chinese Method? Lemon, Turmeric, Ginger, Frankincense oil, Coconut oil, Sweet Almond oil, Myrrh, Cayenne pepper?
If not, please specify why
Acknowledgment
Reasons we will not move forward with encapsulation: Please select box if you understand the statement. Tobacco, drug, or alcohol use during pregnancy. Placenta was sent to pathology for testing. Maternal temp was at 100.4 or higher at the time of delivery. The placenta came into high amounts of maternal fecal matter. Diagnosed with bacterial infection at any stage of pregnancy. Has HIV or any bloodborne illness.*

I acknowledge I do not have any of the above
Client Responsibilities:
I understand that I am required to ask my nurse for my placenta when in postpartum. When delivering in a hospital, I will sign the release form to obtain my placenta upon discharge from the hospital. I may bring my placenta home covered in ice or give it to my encapsulator in my room before I leave the hospital.

If I deliver in a birthing center, I will ask the nurse to keep my placenta for me tagged with my name and date of birth to keep deep froze for our pick up. I understand once I've delivered, I will contact my encapsulator directly, as soon as possible.

Once I've delivered & I have my placenta in hand, I understand that it is my responsibility to contact my OYPE encapsulator directly via text or phone call between the hours of 8am-8pm. I understand my encapsulator will not do overnight pick ups.

I understand that if my placenta is left out for more than 4 hours before being covered in ice, refridgerated or frozen, my placenta will be deemed unsuitable for consumption & no refund will be given.
I have completed this form to the best of my ability and knowledge and agree to inform my encapsulator Shea Lopez-Barela, Stephanie Kowcaz, Chrashae Wagner, or Callie Caraballo of any changes in the above information. I have been informed & understand the contraindications to the requested placenta process and agree that I do not have any pre exsisiting or exsisting condition(s) that would make the requested processing of my placenta unsuitable or unsafe.
I acknowledge that when I'm ready for my placenta to be picked up, that my Encapsulator call to will ask several questions about my medical history.*
Yes, I do
Date Signed

MonthDayYear
Date
Should be Empty:

Organically You Placenta

Client Intake Form

Acknowledgment

Client Responsibilities: