Placenta Encapsulation Agreement

  • Placenta Encapsulation Agreement

    Dacia Celis CD(DONA) and CBE

  • Information shared will remain confidential and is not shared nor distributed to third parties and is used for informational purposes only.
  • Format: (000) 000-0000.
  • Contact's Relation to You:
  • Has your baby arrived?*
  • Estimated Due Date*
     - -
  • How did you hear about me?*
  • Have you had any of the following during your pregnancy, even if you have been treated?*

  • Infections during pregnancy and/or birth may prevent encapsulation from being a safe and viable option. Please refer to your care physician for questions regarding the health of your placenta.

    There are certain health ailments that may prevent safe consumption of your placenta. Be sure to check with your provider to be sure it's a viable option for you.

  • *If a situation arises and you cannot consume your placenta, I do have other options for you such as prints or keepsakes to capture the beautiful journey you shared with your baby.*

  • Providers Promise & Instructions

    Please initial in the space provided to indicate that you have read and understand the information below.

  • You will receive easy placenta storage and packaging instructions via email to take with you to your birth place. I will pick up your placenta from your birthing location and process it in my dedicated workspace. A 72-hour turnaround is ideal, weather, work, holiday, busy, and weekend days-permitting. Once your placenta is processed, I will contact you to schedule a time for me to drop off or for your support person to pick up the placenta products. I follow strict safety and sanitation protocols with every placenta. I am OSHA trained in handling blood and bodily fluids, as well as food safety regulations. I am efficient in preventing and containing infectious disease to allow safe handling for every client's placenta. I am a professional. My equipment and workspace is fully washed and sanitized between clients. I guarantee that everything you receive back is yours and only yours.

  • Client Wishes

    Wild Sage Birth encapsulates placentas in the Traditional Chinese Medicine method, where I steam and then dehydrate the placenta. This gets rid of any bacteria (bacteria cannot live above 135 degrees Fahrenheit). For the dehydrating process, I dry the placenta for the safety standard of 24 hours.
  • I would like my placenta to be steamed with:*

  • Placenta Broth

    The broth is made up from the water, steaming ingredients (if applicable), and placental fluids from the steaming process. It contains many nutrients lost during the steaming process and tastes like herbal tea.Reported benefits include an immediate energy burst, hormone balance, and feelings of well-being. Use it as you would chicken, beef or bone broth to heat and simply sip on. You can also mix it with your favorite lemon or ginger teas.You will receive it in large ice cubes to pull one dosage out at a time. If kept frozen, they are good for 6 months. If kept in a deep freezer, up to a year or possibly longer.This option is not available if you choose the Raw method.
  • Would you like the Placenta Broth ($25)?*

  • Tincture

    It's the gift that keeps on giving! For tinctures, a small portion of your raw placenta or the dehydrated powder is placed inside a tincture bottle with high grade alcohol to create your own personal tonic. Tinctures never expire, so you can use this during later times of stress (going back to work, relationship stress, menopause, life changes, loss/grief, etc).
  • Would you like a Tincture ($75)?*

  • Prints

    A placenta print is using your baby's placenta to make a print on canvas or watercolor paper as a keepsake. The design tends to look abstract or like the "tree of life". The colors used are not placed on your placenta, so you can still encapsulate it. Some people like to frame and hang it in their child's bedroom as a keepsake.
  • Image field 47
  • Image field 48
  • Would you like Placenta Prints ($50)?*
  • Would you like an Umbilical Cord Keepsake?*
  • If so, which shape would you prefer the umbilical keepsake to be (subject to change depending on the size and variation of cord)?

  • Travel Fees

    **VERY IMPORTANT** Please initial in the space provided to indicate you have read and understand the information below.

  • Pick up and drop-off within the Denver Metro Area (25 miles of the zip code 80013). If you are located outside of the service area, there is an additional travel fee, up to $50, depending on your location. Utilizing your own pick up and drop off is an option as well.

  • We prefer to have:*
  • Select any that you would like:*

  • Client Responsibilities

    Please initial in the space provided to indicate you have read and understand the information below.

  • ● Talk to your care provider during a prenatal visit about your intended birth place’s policies in regards to releasing the placenta.

    ● If you are birthing in a hospital: remind your care providers upon admission that you plan to take your placenta and remind them again during pushing and delivery. An extra measure is to put it in your birth plan if you have one.

    ● Please provide your blood work with HIV & Hepatitis B/C status to dacia@intuitivebirth.com or text to 303-906-0278.

    ● If your placenta is in a container, LEAVE IT IN THERE and put it in your cooler with ice (ice ideally in the bags you bring).

    ● The placenta can remain at room temperature for up to 4 hours following the birth. Refrigerate or put it on ice as soon as reasonably possible. Improperly handled placentas are susceptible to spoilage.

    ● Do not let the placenta out of your sight. I cannot encapsulate a placenta taken to Pathology, unless it is deemed medically necessary or considered otherwise unsafe for consumption.

    ● Call or text message me at 303-906-0278 after the birth to arrange a time to pick up the placenta. Please call between 8am and 9pm.

    ● If you are not able to contact me within 4 days of the birth, please freeze the placenta until you are ready for pickup.

    ● Encapsulation and delivery takes 2-5 days for a refrigerated placenta. A frozen placenta will take an additional 1-2 days so that it can be safely thawed.

    ● ***Please contact me if you are unsure if GBS, Pre-eclampsia, or Meconium are a concern for encapsulation. I am happy to provide you with any information & research to help you decide what is best and safe for your family.***

  • Limitations and Disclaimer

    Please initial in the spaces provided to indicate you have read and understand all the information below.

  • Payments, Refund Policies & Cancellations

    Please initial in the space provided to indicate you have read and understand the information below.

  • A non-refundable retainer fee of $50 is due at the time of contract signing. This secures your spot in our calendar and prioritizes your needs. The $50 retainer fee goes towards your overall purchase.

    ● Remainder payment in full is due at time of placenta pick up. Your placenta cannot be processed until it has been paid.
    ● You may cancel this contract at any time, but the $50 retainer is non-refundable and covers time spent prenatally and holding aside your space on my calendar.
    ● If you cancel after I have picked up your placenta but before preparation begins, I will return your placenta to you upon request and refund your remainder payment minus the deposit, however, if you live beyond 25 miles of my business location, travel fees will apply. I live in Aurora (80016).
    ● If you cancel after the encapsulation process has begun: no refund will be given even if you choose not to receive delivery of the finished capsules and/or other services.

    ● If you have already delivered, the full payment is due upon signing of this agreeement.

    I accept Zelle, Venmo, CashApp, or cash in-person.

  • I understand and acknowledge that choosing to encapsulate my placenta is not intended to prevent or treat any physical or mental diseases, ailments or symptoms and that I am choosing to consume my placenta for my own personal beliefs, whether it be spiritual or cultural. I acknowledge that there are no statewide regulations preventing me from obtaining and encapsulating my placenta.

    I acknowledge that Wild Sage Doula Co. has provided me with concrete information about the potential benefits and risks of placenta encapsulation, and have read all included documents. I understand that my placenta will be handled and encapsulated according to OSHA bloodborne pathogens universal precautions and Colorado/USA Food Safety and Handling standards, and will be prepared, cleaned, cooked, dehydrated and put into pill form in a sanitary and disinfected work space upon receiving my placenta capsules from Wild Sage Doula Co. I waive any and all rights to hold either Wild Sage Doula Co. or Dacia Celis responsible for any undesired effect of consuming the capsules.

    I put full trust and acknowledgement that it is being handled in a sanitary and safe environment. I have disclosed to Love In Motion LLC my STD status. I understand that upon receiving the placenta pills, Wild Sage Doula Co. is not liable, including but not limited, to any other person(s) ingesting my own placenta capsules.

    I grant permission for Wild Sage Doula Co. to transport my placenta for preparation and delivery of completed capsules. I understand that my placenta will be handled and encapsulated according to OSHA bloodborne pathogens universal precautions and Food Safety and Handling standards. I understand my placenta will be cleaned, steamed, dehydrated and put into capsule form in the sanitary and disinfected work space indicated above.

    I do not hold Wild Sage Doula Co. responsible or liable for any transport mishap that is beyond her control (ex. car accident or detainment).

    I understand that Wild Sage Doula Co. is not a pharmacy, pharmaceutical  representative, holistic practitioner, herbalist, homeopath or medical doctor. Benefits of placenta encapsulation are supported by anecdotal maternal experience and have not been evaluated by the Food and Drug Administration. Placenta encapsulation or placentophagy is intended solely for ingestion by the mother who has birthed the placenta(s) and not for other individuals and is not guaranteed to produce specific results. The services offered are not clinical, pharmaceutical, or intended to diagnose or treat any condition. Families who choose to utilize the services take full responsibilty of their own health and for searching and using the offered services. Wild Sage Doula Co. makes no guarantee as to capsule efficacy, but does guarantee the highest quality service.

    Always speak to your care provider regarding any questions about your health, safety, and well-being. Placenta services are not meant to be a replacement for medical advice, medical care or medicine. If you experience symptoms of postpartum depression, low milk supply, etc. please call your care provider to discuss your symptoms and how to feel better, as well as how to treat any existing symptoms or potential conditions. While many woman have found placenta encapsulation to be a wonderful and amazing gift, you are still encouraged to seek appropriate assistance and medical care when neccessary. It is important to ask for help if you need it.

    I agree that I am paying for the encapsulation service only, which is not clinical, pharmaceutical, or intended to diagnose or treat any condition. 

    My health care provider and I have determined that my placenta is healthy and suitable for encapsulation. My placenta does not contain any transmittable diseases such as Hepatitis A, B, C, or HIV/AIDS. The placenta has been handled in a manner appropriate for safe food preparation since the birth.

    I understand I am responsible for payment in full by the time my placenta is picked up and acknowledge that if I default on payments or fail to pay, that my placenta cannot be processed.

    I understand that Wild Sage Doula Co. views each placenta as a sacred connection between mother and child and will treat it accordingly. I will not hold Wild Sage Doula Co. responsible if my placenta is accidentally damaged during the encapsulation process.

    I understand that Wild Sage Doula Co. does not determine whether my placenta should be consumed and makes no guarantee of my personal results from the capsules. The capsules should not be taken during times of illness, such as the common cold, flu, or mastitis. I understand that taking the capsules in any manner other than as labeled can have undesirable results.

    I understand that Wild Sage Doula Co. will keep this document on file as a record of our agreement. No copies will be released to any third parties and all client information will be kept strictly confidential. The information provided has not been evaluated by the Food and Drug Administration.

  • Please sign below to indicate that you have read, reviewed and agree to the preceding information, as well as the following:

    I have read, understood, and agreed to the above procedures, information, and statements of policy. By signing my name below, I give my consent to release my healthy placenta to my specialist for the purposes of encapsulation.

    I accept the responsibility of gaining possession of the placenta after the birth, handling and immediate cooling/storage of the placenta appropriately prior to the specialist taking possession of it, and notifying the specialist of my birth within 72 hours while the placenta is being appropriately cooled and stored.

    I authorize the release of my placenta to my specialist and I authorize transportation of my placenta for preparation. I have honestly disclosed all pertinent health details and preparation preferences on this form or by communicating with my specialist.

    I understand that upon receiving the completed capsules, my placenta specialist is not liable for the usage or effects of the services, including but not limited to any other person(s) ingesting my own placenta capsules.

    Upon receiving my completed services, I waive any and all rights to hold my specialist responsible for any undesired effect or differing benefits of consuming the capsules.

  • Date
     - -
  • We will be paying our non-refundable $50 deposit / full amount today via:
  • Should be Empty: