Placenta Encapsulation

Placenta Encapsulation Client Intake Form

Placenta Encapsulation is the act of taking a fresh, raw placenta, washing the placenta, steaming or slicing the placenta raw, dehydrating, grinding and putting the placenta powder into consumable capsules. All processes are done with respect and education of that placenta and in a sanitary environment. My business is adhering to strict OSHA guidelines and I am following 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. I am not a licensed medical professional such as a care provider or physician and I am not able to diagnose, treat or prescribe for any health condition. Services and 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. All information is held at strict confidence. At no given point is information disclosed or shared without client’s written consent.
Today's Date*

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Name*

First NameLast Name
Birth Date*

MonthDayYear
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Expected Delivery Date or Date of Delivery*

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Name of Hospital/Birth Center*
Client Responsibility:

It is the clients responsibility to notify me within 8 hours of the birth so that we can connect to make arrangements for pickup or drop off. Failure to do so may result in delayed placenta preparation and may cause decreased potency of nutrients, hormones and other beneficial attributes of the placenta. Improper storage of the placenta prior to pick up or drop off may result in spoilage. It is your responsibility to discuss the 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. This can be done by placing the placenta on ice until it can be retrieved for preparation and encapsulation.

It is your responsibility to inform me of any known blood borne illness(es) or other health issues (such as HIV, Hepitisis, etc)that could place me or any other person who may come in contact with your (specifically maternal and fetal blood as amniotic fluid) at risk. Some specific sexually transmitted diseases such as Hepatitis or herpes may preclude me from offering placenta encapsulation in my home.

My responsibilities - as your encapsulator - include maintaining client confidentiality, committing to preparing and returning your capsules within 72 hours of receiving your placenta and upholding the highest standards of cleanliness, safety and quality of professional placenta preparation services. In the event that I am unable to be available for your placenta encapsulation, I will provide a backup placenta specialist who is capable of providing 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, I will not be able to encapsulate without an additional waiver. Other conditions, such as signs of infection during labor, may mean that consuming your placenta could be harmful to your health. I 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 me 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

Deposits are NON-Refundable. If I have already taken possession of your placenta and you choose to not go forward with services I will return your placenta to you for disposal. There will be no refund and payment will be due IN FULL once preparation has begun, even if you choose not to take delivery of the finished capsules. By signing below you agree to pay the full cost of the services you've selected using one of the applicable payment methods.

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 8 hours of my birth. I understand the importance of appropriate handling and storage of the placenta. By signing below, I authorize Tyanna Haynes, Becoming One, LLC for the purposes of placenta encapsulation and keepsake preparation for my own personal use.
List any communicable diseases (HIV, Herpes, Hepatitis B, etc). Type N/A, if not applicable.*
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Doulas Name and Phone Number*
Cashapp: officialtyannaZelle: becomingonellc@gmail.com

Services:*

Essence of Motherhood Package

This package includes Full Placenta Encapsulation Pill, Umbilical Cord Keepsake, Placenta Print, and hand picked gifts for you to support your postpartum journey. This package does require a $100 deposit for the purchase of supplies. The deposit is applied to the total cost of services.

$275.00 Quantity

Lifelines and Legacy Prints

This package includes an Umbilical Cord Keepsake and Placenta Print

$45.00

Milk and Honey Session

This session includes all things Lactation Support. Sessions are by the hour, please change the hour quantity if you are interest in booking multiple hours. There is a 1 hour limit per day.

$ Free Hours

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$0.00

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Placenta Encapsulation Client Intake Form