I, ____________________________ (Client’s Name) understand and acknowledge that in accordance to my state laws and bylaws, choosing to encapsulate my placenta is not intended to prevent or treat any physical or mental diseases, ailments or symptoms and that I am choosing to consume my placenta for my own personal beliefs, whether it be spiritual or cultural.
I acknowledge that my placenta specialist has provided me with information about both the benefits and risks of placenta encapsulation. I understand that my placenta has been handled and encapsulated according to OSHA and State Food Safety and Handling standards, and has been cleaned, cooked, dehydrated and put into pill form in a sanitary work space. Upon receiving my placenta capsules from my placenta specialist, I waive any and all rights to hold the specialist responsible for any undesired effect of consuming the capsules. This may include an oversupply in milk, hormonal shift, anxiety or sleeplessness. These side effects are rare, but have been reported. I agree to contact my placenta specialist immediately if and when I experience any of these side effects.
I do not hold my placenta specialist responsible or liable for any transport mishap that is beyond their control (ex. car accident or detainment), and understand that I am choosing to have the specialist encapsulate my placenta in the specialist’s home.
I put full trust and acknowledgement that my placenta is being handled in a sanitary and safe environment. I put trust and faith that my placenta specialist has been training correctly to prepare placenta remedies.
I confirm that I have been tested for STD’s and the results were negative. If my blood results indicated hepatitis or HIV/AIDS, I understand that I will allow my placenta specialist to prepare in my home, using my own supplies.
Universal precautions for sanitizing are the same with each client. I understand and trust that my placenta specialist retains liability forms for each client and that I am protected.
I understand that upon receiving the pills, my placenta specialist is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules.
Print Client Name Placenta Specialist
Client Signature Date
Placenta Encapsulation Description: Placenta encapsulation is the process of preparing the mother’s placenta after the birth of her baby by gently dehydrating, powdering and placing it into capsules for the mother to use as she sees fit.
Limitations and Disclaimer: I am not a licensed medical professional and I am not able to diagnose, treat or prescribe for any health condition. Services and fees are for the preparation and encapsulation of your placenta, not for the sale of the pills. No specific benefits or effects are promised. Any benefits will vary from person to person. Some of the ascribed benefits of placenta consumption are supported by research; however these benefits have not been evaluated or approved by the FDA.
Placenta Encapsulation is for natural nutritional supplementation and is intended solely for ingestion by the mother who has birthed the placenta(s) and not for her family members, friends, or other individuals. It is a natural nutritional supplement, and as such, cannot be guaranteed to produce specific results. It is your responsibility to determine whether using placenta preparations may be of benefit to you. The services offered by Alaska Birth Doula are in a culinary capacity and 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, their research & use of products. 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. Mothers experiencing symptoms of postpartum depression, low milk supply, etc. are greatly encouraged to speak to the care provider about how to feel better and 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 will, ideally, pick up your placenta the day you give birth. Please notify me as soon as possible after the birth so that we can coordinate a pick up time.
I will provide a written explanation of the proper storing and handling of the finished placenta capsules and tincture as well as guidelines for daily ingestion. Should emergency circumstances, such as weather, prevent me from pick-up, we will need to make arrangements to have the placenta frozen.
If I'm unable to pick up within 48 due to personal circumstances such as illness, I will have a backup available to you.
♦ It is your responsibility to discuss release of your placenta from the hospital where you give birth and to ensure proper storage of your placenta in a refrigerator or cooler with the placenta placed on ice until it can be picked up or delivered for preparation and encapsulation. Please contact me if you need assistance with this.
♦ It is your responsibility to notify me as soon after delivery as possible. Failure to do so may result in delayed placenta preparation and encapsulation and may cause spoilage of the placenta which would render it unusable for encapsulation.
♦ It is your responsibility to disclose any allergies or sensitivities.
♦ Whether birthing at home or in a hospital or birth center, please ensure that your placenta is kept fresh. It can remain at room temperature for 3 hours following the birth. After that (or sooner if possible) it should be refrigerated or otherwise kept cool. If you are practicing some form of delayed cord cutting or lotus birth, ice packs may be wrapped up with the placenta to prevent spoilage. If it is going to be more than 3 or 4 days before the placenta can be prepared, it should be frozen. A frozen placenta will take somewhat longer to prepare since I prefer to gently defrost it prior to preparation.
♦ Please ensure the placenta is placed in a sanitary container OR double bagged in gallon size freezer bags.
♦ It is important to note that there may be circumstances under which your placenta can not be used. Significant abnormalities of the placenta may necessitate your doctor or midwife sending your placenta to Pathology for further examination. Other conditions, such as signs of infection in the mother during labor, may mean that consuming your placenta will not be beneficial to you. If in doubt, I will consult with you before proceeding. It should be possible to claim your placenta after a c-section. If your placenta is deemed unfit for encapsulation, a refund for services, less a $50 nonrefundable reservation fee, will be issued.
Instructions for Labor Support Team
In order to provide a safe and effective end product, it is imperative that the placenta is handled in a safe manner after the birth.
The placenta can be kept at room temperature for up to 3 hours for the purposes of delayed cord severance. Once it is severed please place in cooler, as detailed below.
► Ensure that the placenta does not come into contact with any chemicals, or medications once delivered.
► If a sample is required for pathology, take a small sample, using sterile scissors in the delivery room. If the placenta leaves the room I will not be able to provide this service to her.
► As soon as possible, place placenta in a sanitary container or double bag in gallon size plastic storage bags and place in the cooler on ice. It may be sent home with someone right away and placed in the refrigerator, or picked up at the hospital or birth location as per our conversation after delivery.
Shanna Switzer, CD(DONA), GBCE, Alaska Birth Services