Prima Placenta Services Registration Form

Placenta Services Registration Form
Name *

First Name Last Name
EDD/ Baby's Birth Date *

- Month - Day Year
Partner's Name

First Name Last Name
Phone *

- Area Code Phone Number
Cell Phone

- Area Code Phone Number
E-mail *
Preferred Way to Communicate *

Phone Text Email

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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.
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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.

My Products

Placenta Encapsulation $ 280.00

Placenta Tincture $ 50.00

Placenta Smoothie and Frozen Cubes $ 50.00

Placenta Salve $ 50.00

Total $ 0.00
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Placenta Services Registration Form

On Call Preparation

When would you like your placenta prepared?

Options and Preferences

Cord Keepsake and Watercolor Prints

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