Placenta Encapsulation and Print Request Form

Client Details:

Full Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Support Person's Full Name*

First NameLast Name

Support Person(s) Phone Number*

Please enter a valid phone number.

Estimated Due Date*

Date

Planned Birth Location*

Birth CenterHomeHospital

Are you delivering via a planned cesarean?*

YesNo

Booking Type:*

Booking in AdvanceCurrently In LaborBaby has already been born

If baby is already born what is baby's date of birth

Date

Location where Placenta will be Picked UP*

Name of Hospital, Birthing Center. If Home birth or you have already taken placenta home type Home

Address of where Placenta will be PICKED UP:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Address of where Placenta will be DELIVERED :*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Placenta Service Options : Please note that a cord keepsake is included with this service*

Traditional Method (TM) of Encapsulation - The placenta is cleaned, inspected and steamed before slicing for dehydrating. In the steaming water lemon, ginger and a hot pepper are placed. It is believed by including these elements into the steaming water we are introducing a grounding, balancing and detoxifying effect for the mother. Many say this method of encapsulation allows for a slower more gentle release of hormones into the mothers body upon consumption. Steaming will however cause considerable shrinkage and this method tends to yield fewer capsules.*

Steamed onlyUnsureI am not encapsulating (placenta print only)

Raw Method of Encapsulation - The placenta is cleaned, inspected and thinly sliced for dehydration. Many mothers agree this method of encapsulation gives a stronger release of hormones upon consumption **The cost is the same for either method $365***

Raw onlyUnsureI am not encapsulating (placenta print only)

Placenta Tincture -A small slice of the cleaned placenta is infused in 4oz of high proof gluten free alcohol. This is consumed after the capsules are finished and can be stored and consumed for many years ahead. Great for menstruation, postpartum recovery, menopause etc.

Tincture ($45)

Salve - A thick balm made from organic ingredients that can be used for cradle cap, diaper rash, cracked nipples, perineal tears, cesarean section scars.

Salve ($45)

Placenta Print pink stain ADD ON only ($30)Placenta Print multi color ADD ON only ($50)Placenta Print (pink stain) and Cord Keep sake ONLY without encapsulation ($120)Placenta Print (multi color stain) and Cord Keep sake ONLY without encapsulation ($150)

Blood Type*

Are you HIV/AIDS positive?*

Complications or medications? (If not, type N/A)*

Allergies or concerns? (If not, type N/A)*

Please check each of the following boxes:*

I understand that placenta services offered by Here For You Doulas are not clinical, pharmaceutical, or intended to diagnose or treat any condition.I understand that placenta services offered by Here For You Doulas are not clinical, pharmaceutical, or intended to diagnose or treat any condition.I confirm the information provided is accurate to the best of my knowledge.I give permission for my placenta to be processed by Here For You Doulas for personal use only.

Signature*

Date of Signature*

Example: M/D/YYYY

Please verify that you are human*

Anything else you'd like us to know?

If you have any questions prior to purchase feel free to reach out to us at totalsupport@hereforyoudoulas.com

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Placenta Encapsulation and Print Request Form

Birth and Delivery

Placenta Preferences

Encapsulation style

Add-on Services:

Placenta Print Services:

Medical History

Consent

Final Notes