New Client Form

Placenta Processing Preference & Product Order Form
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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.
$295.00
Item subtotal:$0.00



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 Would you like an umbilical cord keepsake?Keepsake ShapeKeepsake Finish
Item subtotal:$0.00



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 Quantity
Item subtotal:$0.00



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 Quantity
Item subtotal:$0.00



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 Type of Placenta Print
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Delivery Method & Travel FeesA personal connection with our clients is of utmost importance to us, thus we give our clients their choice in how they receive their final products. The final product can either be mailed to you insured for the total of the order with USPS or hand delivered by us if you live within the service radius. If you are birthing outside of our service radius please be sure to select the “Delivery Method” option and know that your final product will be mailed back to you free of charge and insured for the total of your order. If you are going to have it hand delivered to you please figure that from Sanger Tx. If you are outside of the service radius and there is a charge to meet please select that option.
$ Free Preferred Delivery Method
Item subtotal:$0.00



Total

$0.00
Please specify custom requests or other important information.
(If you have questions or need clarification prior to submission, call/text Angie Stewart at 940-594-8297)

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 take possession of the placenta, there must be a completed contract on file, the non-refundable deposit, and all remaining balances paid at the 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 information for you and your partner. 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 once you have the placenta secured so I can come pick it up. I will aslo communicate to you on this thread and it will let you know when I am on the way to pick up the placenta, 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. If the facility is giving you are hard time please have a designated person that is able to take the placenta out to the car until I am able to pick it up. 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 $75 non-refundable deposit is due at the same time you submit your completed contract. The $75 goes toward your overall balance due and guarantees service at the time of delivery. DPE/DCPE/Angie Stewart will accept late-in-pregnancy and same-day clients. You will receive an invoice reflecting your total balance as soon as we receive your order form and deposit. 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, at the time DPE/DCPE/Angie Stewart take possession of the placenta. 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 $75 deposit. Absolutely no refund will be issued after DPE/DCPE/Angie Stewart takes possession of the placenta.

In the case of hospital/birthing facility error or physician refusal to release the placenta, for any reason, it is the responsibility of the hospital/birthing facility to provide a full/partial refund, to the client for the cost of any fees paid for encapsulation and subsequently lost due to hospital/birthing facility error or physician refusal to release the placenta. It is the client's responsibility to contact the hospital/birthing facility-employed patient advocate and/or the ombudsman to initiate reimbursement from the facility. It is the responsibility of the client to gather and submit all requested/required documentation, to the appropriate parties, within the designated timeline, to resolve the issue properly. DPE/DCPE/Angie Stewart will absolutely provide the client with all supporting documentation possible in order to support their efforts in obtaining a refund from the hospital/birthing facility. DPE/DCPE/Angie Stewart is available to speak with any hospital/birthing facility representative and the client, via conference call, to ensure proper client reimbursement from the facility.

Delivery of final product

The client has the option of how they receive their final product. It will either be shipped via an insured package with USPS or hand delivered by Angie Stewart to the client. The product is ready to ship within 48-72 hours with delivery via USPS 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. Should you wish to have your items hand-delivered to you, your product will be at your door within 72 hours- 5 days from the time DPE/DCPE/Angie Stewart takes possession of the placenta. There is a travel fee for hand delivery of the final product that is added to the final balance and is due upon DPE/DCPE/Angie Stewart taking possession of the placenta.

The travel fees are: (Please calculate from Sanger, Tx)

$50 for hand delivery within service radius of (0 miles - 45 miles)

$75 for hand delivery outside of service radius (No more than 70 miles, anything beyond that will have the final product mailed. (46 miles - 70 miles)

The following are accepted forms of payment for the $75 non-refundable deposit & final payment.
- Zelle: 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.
The remaining balance is due, in full, at the time DPE/DCPE/Angie Stewart takes possession of the placenta, with the request for final payment being issued via Angie Stewart. You will receive a payment request for the remaining balance via the payment platform used to submit your deposit (unless otherwise specified) at the time we are notified of active labor. Once the placenta is secured and we are dispatched for pickup, please approve the request to remit the final payment.

Dallas Placenta Encapsulation Service Contract

Please complete the contract below. The $75 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,client name, henceforth "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. Initials
- 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. Initials
- 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. Initials
- 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. Initials
- 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. Initials
- 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. Initials
- 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. Initials
- 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 custody is given to DPE/DCPE/Angie Stewart. Initails
- I agree to pay a $75 non-refundable deposit at the time of contract submission. Initials
- I understand the remaining balance is due, in full, at the time DPE/DCPE Angie Stewart takes possession of my placenta, unless I am a same day client, at which time, full payment is due PRIOR to DPE/DCPE/Angie Stewart will be dispatched for pickup. I will notify DPE/DCPE/Angie Stewart if I need to arrange a payment plan prior to delivery. Initials
- I agree to text DPE/DCPE/Angie Stewart stating that I am in labor and the name of the facility I am in route to. I understand I, or my support person, must physically call DPE/DCPE/Angie Stewart once the placenta is secured and ready for transport. Initials
- I agree to have my support person meet DPE/DCPE/Angie Stewart in the designated area, outside the hospital, upon their arrival with the placenta, on ice, IN A DISPOSABLE COOLER. DPE/DCPE/Angie Stewart are not responsible for the return of hard sided coolers. Should I use a non-disposable cooler and wish to have it returned to me, I agree to pay the shipping cost of the return and understand shipping of the cooler will not take place until I’ve remitted the shipping fee.
Initials

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.

Signature Date
Should be Empty:

Client Intake Form - Local

Permission to Post Birth Announcement

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.

Dallas Placenta Encapsulation Service Contract