Placenta Services Registration Form
EDD/ Baby's Birth Date
Preferred Way to Communicate
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Where do you plan on giving birth?
Tell me about your upcoming birth
This is my first baby
This is my second/ third/ or more baby
I am planning a vaginal birth
I am planning a cesarean birth
I am planning a VBAC
I am planning an unmedicated birth
I am planning on having an epidural
Tell me more about you and your needs
Ages of older children (if any):
Do you have an infectious diseases such as HIV, AIDS, Hepatitis, Herpes or Lyme Disease?
Please list any infectious diseases you have or may have.
Please any complications you are experiencing with this pregnancy.
Please list any medications you are taking during this pregnancy.
I experienced one or more of the following during a previous pregnancy.
Challenging physical recovery
Challenging emotional recovery
Low milk supply
Other postpartum mood disorder
I had a great recovery
I'm not sure
Is there anything you would like to share with me about your previous postpartum recovery/recoveries?
Why are you choosing to ingest your placenta? What benefits are you looking forward to?
On Call Preparation
Prima Postpartum is dedicated to providing placenta services that are safe, reliable and high quality. Because of this, I will only process your placenta in your home.This greatly reduces the risk of cross contamination and mix ups. Arrangement should be made so that your placenta is packed up and ready to go after delivery.*If your placenta will not be processed within 72 hours of birth it will need to be frozen and will then need 24 hours to thaw before encapsulation.*Contact me once you know for sure you are in labor and once again when your and your baby have settled in. I can come to your birthing place within 12 hours of your baby's birth to pick up your placenta and take it to your home for processing.. I will need access to your kitchen in order to process your placenta. E-sign below that you understand and agree.
When would you like your placenta prepared?
Immediately following birth, your placenta should be placed into two freezer bags and placed into a Tupperware style container. It should then be refrigerated until it is ready to be picked up for processing. If you do not have access to a refrigerator, it can be placed on ice in a cooler. If you know your placenta is not going to be processed within 72 hours of birth, it should be frozen until you are ready to have it encapsulated.
I would like my placenta processed
as soon as possible after birth. I will have a trusted person meet you at my home with my placenta and give you access to my kitchen. They will also give you access the following day to complete the encapsulation process.
when I have returned home from my birthing place or at a later date. I will freeze my placenta after birth and allow 24 hours for it to thaw before processing.
Options and Preferences
On average, a placenta will produce between 130-180 capsules. Usually the bigger the baby, the bigger the placenta. You can anticipate receiving 22 capsules per pound of baby .For example:6lb baby = 132 capsules8lb baby = 176 capsules. The cost for this service is $190 including on call pick up of your placenta, quick and efficient preparation in your home and completion of the capsules 1 day later. In some cases, the processing may take up to 2 days but never longer!
Do you have any food or spice allergies? If yes, list them.
I would like
Cord Keepsake and Watercolor Prints
The umbilical cord that connected your new baby to your womb during the pregnancy played a key role in delivering oxygen, nutrients and essential blood to your baby during gestation.To honor and treasure the umbilical cord it can be dehydrated into a heart or spiral shape and kept with other mementos for your baby.Occasionally, the OB may not include your umbilical cord with the placenta, especially in the case of cord blood banking/ donation. In this case, a keepsake will not be an option.
What Shape would you like me to create with your baby's umbilical cord? (no extra charge)
I don't want a cord keepsake
Are you interested in having a placenta print on water color paper?
Yes, I want a print made using the blood that is on my placenta
Yes, I want an artistic print of my placenta using food grade paints
No, I'm not interested in a placenta print
I am interested in the following referrals for my prenatal and postpartum wellness and recovery. Please check all that apply. Referrals will be emailed within 72 hours.
I am interested in the following referrals:
Prenatal Massage Therapist
Prenatal Mental Health
Breastfeeding Support Group
Mother Blessing Celebration
Infant CPR Classes
New Mom Support Group
Mommy and Me Classes
Car Seat Installation Tech
Babywearing Classes and Meetings
Postpartum Mental Health
Postpartum Belly Binding
Pelvic Floor Therapy
Placenta Smoothie and Frozen Cubes
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