Placenta Arts Services
Please complete the following Client Registration, read through the General Information and Policies, and note your preparation preferences along with any information related to your services that I should be aware of. I respect your right to privacy and assure you that all answers are held in strictest confidence.
Street Address Line 2
State / Province
Postal / Zip Code
Name of Partner or Support Person
Phone Number of Partner or Support Person
Current Pregnancy Information
Baby's Due Date
Name of Planned Birth Place
Name of Midwife or OB/GYN
Is this your first birth?
Have you had any of the following during this pregnancy (please check all that apply even if you have been treated, make a note in the "Other" Category if you have a history of the following or any that are not listed)
Group B Strep (GBS+)
Urinary Tract Infection (UTI)
Other STD/STI (Chlamydia, Gonorrhea, HIV, other)
Do you have any health complications? Are you taking any medication?
Placenta Services Preferences
The placenta will be picked up from your birth place on the day your baby is born and the capsules will be returned upon completion.
Preferred encapsulation method
Raw Start (not steamed)
A free cord keepsake is included in your package. This is optional. Would you like a cord keepsake?
Choose a Placenta Arts Package.
Are you interested in any of the following add-ons?
Berry Flavor Capsules ($15)
Special Instructions. Comments. Questions.
Photos of your placenta or placenta products may be taken for educational, promotional, or record keeping purposes. No identifying information will be shared under any circumstances. If you would like a copy of any photographs taken, please note this request:
Yes, I agree with the statement above and consent to photos being taken.
Yes, please take photos of my placenta to send to me.
No, I do not agree with the statement above or consent to photos being taken.
Please "agree" to the following.
Talk to your care provider during a prenatal visit about your intended birth place’s policies in regards to releasing the placenta. Sign any forms required and have them placed in your file. If you are birthing in a hospital: remind your labor nurse upon arrival, and on change on shift if applicable, that you plan to take your placenta. Following the birth, your placenta must be placed in a sealed container or double ziplock gallon-sized bags and labelled with your name. You are responsible for ensuring that you have met all the requirements of your birthing facility and completed the appropriate paperwork for release, if any. You are responsible for the safe handling and appropriate storage of your placenta prior to pickup by the specialist.
Call or text message me at (870) 413-6840 after the birth to arrange a time to pick up the placenta. Please call between 8am and 8pm. If you are not able to contact me within 3 days of the birth and the placenta has been appropriately refrigerated since the birth, please freeze the placenta until you are ready for pickup. Encapsulation and capsule delivery generally takes 2-3 days for a refrigerated placenta. A frozen placenta will take an additional 1-2 days so that it can be safely thawed.
Permission is granted for your specialist to transport your placenta for preparation and delivery of completed capsules. Your placenta will be handled and encapsulated according to OSHA bloodborne pathogens universal precautions and Virginia Food Safety and Handling standards. Your placenta will be cleaned, steamed (if indicated above), dehydrated and put into capsule form in the sanitary and disinfected work space indicated above. The specialist is not responsible or liable for any issues preventing provision of the services that are beyond her control (ex. car accident, detainment, placenta sent to Pathology Dept., etc)
A $50 non-refundable deposit is due upon completing this form. Payment in full is due before delivery of the capsules. You may cancel this contract at any time prior to services being rendered. If you cancel after I have picked up your placenta but before preparation begins, I will return your placenta to you upon request and no further payment is required. If you cancel after the encapsulation process has begun: the balance is due in full and no refund will be given. If your placenta is unable to be encapsulated due to medical circumstance or contamination, no further payment is required. Payment plans can be arranged in advance, when necessary. Please use the paypal link on https://www.babieshappen.com/placenta-arts for payments.
Your placenta specialist is not a pharmacy, pharmaceutical representative, holistic practitioner, herbalist, homeopath or medical doctor. Benefits of placenta encapsulation are supported by 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 her family members, friends, or 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 responsibility of their own health and for researching and using the offered services. Your placenta specialist makes no guarantee as to capsule efficacy, but does guarantee the highest quality of 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 treat any existing symptoms or potential conditions. While many women have found placenta encapsulation to be a wonderful and amazing gift, you are still encouraged to seek appropriate assistance and medical care when necessary. It is always okay to ask for help.
I agree that I am paying for the encapsulation service only, which is not clinical, pharmaceutical, or intended to diagnose or treat any condition. No refunds for services will be given. My placenta does not contain any transmittable diseases such as Hepatitis-B, -C or HIV/AIDS. My care provider and I have determined that my placenta is healthy and suitable for encapsulation.The placenta has been handled in a manner appropriate for safe food preparation since the birth.
I understand that my specialist views each placenta as a sacred connection between mother and child and will treat it accordingly. I will not hold my specialist responsible if my placenta is accidentally damaged during the encapsulation process.
My specialist 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 labelled can have undesirable results.
My specialist 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.
I have read, understood, and agreed to the above procedures, information, and statements of policy. By agreeing 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 my health history and all pertinent health details and preparation preferences on this form. I understand that upon receiving the completed capsules, my specialist is not liable for the usage or effects of the capsules, including but not limited to any other person(s) ingesting my own placenta capsules. Upon receiving my completed placenta capsules, I waive any and all rights to hold my specialist responsible for any undesired effect or differing benefits of consuming the capsules. Signature:
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