New Client Form - Nationwide

  • Client Intake Form - Nationwide

    Thank you for choosing Dallas Placenta Encapsulation (DPE)/Denton County Placenta Encapsulation (DCPE)! Please complete the form below and submit it along with your signed contract and $150 non-refundable deposit. Don’t hesitate to reach out with questions or concerns. We look forward to serving you and your family!
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  • Permission to Post Birth Announcement


    Once a baby is born and I mail out your capsules, I love to post on my social media a, "Welcome Baby Boy" or "Welcome Baby Girl" post that includes if the baby is a boy or a girl and a sweet little message to you and your family. Sometimes I might include, "First time parents" or something cute about the family or family member. I never use names or initials.
    Does DPE/DCPE/Angie Stewart have permission to post a birth announcement including the baby's gender and a little something about the family or a member or first time parents?

                  
    If you give limited permission, please specify the limits below:   
              

    Please specify the baby's gender below. Be sure to include answers for both/all babies if you are expecting multiples.
       
    *  

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    Preferred Preparation Method Product Image
    Preferred Preparation Method ***PLEASE NOTE: there are preparation method options for those expecting multiples. There is a small fee associated to cover production costs. -TCM (steamed): blended herbs and spices are added to the placenta, then gently steamed prior to dehydration. (If you’d like TCM WITHOUT herbs and spices please specify that at the time of placing your order) -Simple Preparation: no additional heat is used prior to dehydration. -1/2 TCM & 1/2 Simple Preparation: the placenta is divided in half. One half receives TCM and the other receives Simple Preparation.
    $400.00
    Item subtotal:$0.00
      
    Umbilical Cord Keepsake Preference Product Image
    Umbilical Cord Keepsake PreferenceAn umbilical cord keepsake is included with the encapsulation service. Umbilical Cord Keepsakes are created by detaching the remaining cord from the placenta and shaping in your choice of shape. If you have a custom request, please specify at the time of placing your order. (Subject to cord length and thickness). The final keepsake may be kept natural, or it can be painted with a variety of metallic acrylic paints. **(Choosing to not have a keepsake made will NOT decrease the price for encapsulation and the cord will be dehydrated and added in with the rest of the placenta powder).
    $ Free
    Item subtotal:$0.00
      
    Placenta Salve Product Image
    Placenta SalveA combination of organic oils, herbs, and placenta powder are infused to create an incredibly soothing skin balm.  The placenta salve can be used for a c-section or episiotomy scars, sore nipples from nursing mothers, diaper rash, baby acne, other minor scarps, wounds, and so much more.  The salve comes to you in a 2 oz. container with a spatula. For additional salve $30.
    $55.00
    Item subtotal:$0.00
      
    Placenta Tincture Product Image
    Placenta TinctureA small piece of placenta is placed into a 4 oz. glass jar, covered with 80 proof gluten-free vodka, and closed off with a dropper lid. MUST sit for a MINIMUM of six weeks to cure before straining and using.  This is best stored in a dark cabinet while it cures.  When you start to run out of this you can add more vodka in and allow it to cure for 6 weeks. For additional tincture $25.
    $45.00
    Item subtotal:$0.00
      
    Placenta Prints Product Image
    Placenta PrintsMade using the residual fluid of the placenta and gently pressing watercolor paper on top to create a stamped image of the placenta.  You get 2 prints. For additional prints $10.  Colored Placenta Print Made using acrylic paint (non-toxic) or watercolor gouache (non-toxic) and gently pressing to watercolor paper on top to create a stamped image of the placenta.  You get 1 print.
    $25.00
    Item subtotal:$0.00
      
    Total
    $0.00

  • Below you will find important information regarding payments, refunds, and contract requirements. PLEASE READ prior to completing and submitting your form.  If you have any questions, concerns, or need clarification please call me or text me at 940-594-8297. 

     

    Contract 

    In order for DPE/DCPE/Angie Stewart to start preparing the placenta, there must be a completed contract on file, the non-refundable deposit, and all remaining balances paid at time of delivery.

    Once the form has been filled out and I have received the non-refundable deposit I will send a "Welcome Text" with all of the information you and your partner will need about the placenta kit and communication about the placenta.  That text thread will be the way we communicate when you arrive at your birthing location, once you start to push, when you have delivered, and when you have shipped your placenta to me.  I will aslo communicate to you on this thread and it will let you know when the placenta kit has been shipped, when the capsules and any other products have been shipped, and the directions for taking them and any other products you purchase.

    If you have any problems with the facility please contact me immediately so I am able to help you navigate the issue.  Most of the facilities have placed a one to two hour window on how long the placenta can stay inside the building.  Please have a designated person that is able to take the placenta out to the car until someone can take it home and get it into the freezer.  Make sure that you have it covered in ice.  

    If there are any questions or concerns that you have, please contact me by calling or texting 24/7.  I am available to you for any of your needs.

    Deposit

    A $150 non-refundable deposit is due at the same time you submit your completed contract. The $150 goes toward your overall balance due and guarantees service at the time of delivery.  This deposit covers the cost of your placenta kit and the cost of shipping it back to me.  DPE/DCPE/Angie Stewart will accept late-in-pregnancy and same-day clients. Same day clients will be refquired to pay the total balance as soon as we receive your order form. You may submit this invoice to your private insurance company for possible reimbursement of encapsulation fees. We have no affiliation with any insurance companies and cannot submit the invoice on your behalf. We do not guarantee you will be reimbursed by your insurance company.

    Payment Schedule

    The remaining balance (after the deposit) must be paid, in full, after the placenta is delivered and secured.  Processing WILL NOT START until full payment has been remitted. Please note, delay in final payment will also delay return time of the final product. Processing time of 48-72 hours begins upon remittance of final payment AND possession of the placenta to DPE/DCPE/Angie Stewart. Payment plans are available upon request. Processing of the placenta will not begin until full payment has been made unless otherwise arranged prior to delivery. 

    The following are the forms of payment I use:

    Zelle:  Mariangela Stewart 940-594-8297

    Apple Pay: 940-594-8297

    CashApp: $MariangelaStewart

    I am also able to take most HSA payments through Square.  We are able to try and see if this works. 

    Refunds

    Refunds are for clients who have paid, in full, upfront and are determined (at the sole discretion of DPE/DCPE/Angie Stewart), on a case-by-case basis. Refunds are given in the total amount paid, minus the one-time, non-refundable $150 deposit. Absolutely no refund will be issued after DPE/DCPE/Angie Stewart takes possession of the placenta.

     

    Delivery of final product

    The final product will be shipped via an insured package with USPS to the client. The product will be ready to ship within 48-72 hours after I receive the placenta.  Delivery from USPS should deliver within 3-5 business days. Once the package has been submitted to USPS, a tracking number will be provided to you. DPE/DCPE/Angie Stewart is NOT responsible for damaged or lost packages once possession of the package is given to the carrier. The package will be insured to the full amount of your product and reimbursed to you via the carrier NOT DPE/DCPE/Angie Stewart. In the event of a lost package or damaged product(s), the client will need to submit a claim with USPS in order to begin the process of reimbursement. The client is responsible for following all required prompts and protocols laid out via the carrier, within the specified time frame given. 

     

     

  • Dallas Placenta Encapsulation Service Contract

    Please complete the contract below. The $150 non-refundable deposit is due at the time of contract submission in order to secure your date on the schedule. If you need immediate assistance completing the form or submitting the deposit, contact Angie Stewart at 940-594-8297.

  • I,, have asked Dallas Placenta Encapsulation/Denton County Placenta Encapsulation/Angie Stewart (henceforth "DPE/DCPE/Angie Stewart") to prepare my placenta in a capsule form for my personal use. Completion of this order form, and remittance of all required fees associated, guarantees service at the time of delivery, and obligates DPE/DCPE/Angie Stewart to render said service as stated in this contract.
    As a condition of service, I make the following assertions:

    • I understand that every woman and pregnancy is different and may have different results. I understand that no guarantee of results is offered or implied.   


    • I release DPE/DCPE/Angie Stewart and any of their representatives from all liability of any side effects I may experience after consuming my placenta products.       


    • I understand DPE/DCPE/Angie Stewart and their representatives are NOT qualified to, nor offer, any diagnosis or treatment of illness. The aforementioned provides a preparation service only.         


    • I understand the guidelines provided for placenta capsule usage are a reference only. I trust my own ability to listen to my body and adjust capsule usage according to my individual needs.      


    • I understand consuming my placenta products during times of illness (such as the common cold, flu, mastitis, etc.) may worsen my symptoms. I trust my ability to decide when to/not to consume my capsules.         


    • I agree to disclose to DPE/DCPE/Angie Stewart if my placenta could potentially contain a transmittable disease, such as but not limited to, Hepatitis A, B, C, HIV/AIDS, STD, MRSA, etc.         


    • I understand that having a GBS or Covid-19 positive test DOES NOT preclude me from encapsulation and it is my responsibility to assert my right to keep my placenta (protected by H.B. 1670, as of September 1st, 2015), should my provider refuse to release it.     


    • I agree to let the birthing facility and staff know that I am keeping my placenta. I assert my placenta has been properly stored in my possession since delivery and has not been to the hospital lab. I will retain possession of my placenta until I ship the placenta and the placenta kit to DPE/DCPE/Angie Stewart. I agree that if I have any issues with my birthing facility I will contact Angie Stewart immediately to help navigate the issue.     


    • I assert that my placenta will be properly stored inside the ziplock bag, placed inside the spill proof container, and then placed inside the other ziplock bag provided in the placenta kit and placed on ice until it has been put into the freezer within 24 hours postpartum. I agree to leave the placenta in the freezer for 48 to 72 hours before it is taken out to be shipped to me in the cooler provided.       


    • I agree to follow the directions provided to me on properly storing the placenta and mailing the placenta. I agree to only mail the placenta and items within the placenta kit on Monday, Tuesday, or Wednesday to insure the placenta is safely delivered to me through UPS Healthcare. I understand that it is my responsibility to make sure I follow the directions on handling and shipping the placenta.       


    • I agree to pay a $150 non-refundable deposit at the time of contract submission.       


    • I understand the remaining balance is due, in full, at the time of delivery. I will notify DPE/DCPE/Angie Stewart if I need to arrange a payment plan prior to delivery.      


    • For Same Day Clients ONLY: I understand if I am a same day client, the full payment is due at the time of form submission not just the deposit. I understand my placenta kit will be mailed out on the next business day.      


    • I agree to keep up with all important communication in the text thread to and from DPE/DCPE/Angie Stewart regarding labor, delivery, and mailing the placenta kit to Angie Stewart.         


    I have read and understood the terms and conditions as outlined in this form. The answers I provided are true and accurate to the best of my knowledge.


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