Name

Email Address

Phone Number

Delivery Zip Code

Estimated Due Date (EDD)

In what form do you prefer your placenta? In what form do you prefer your placenta? Capsules Only Capsules & Tincture Ground Placenta Only (No Capsules or Tincture)

Please List Any Allergies You Have

Do you have any active or past infection of HIV, AIDS, Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D, MRSA, VRE, Ebola, Gonorrhea, Syphilis, Chlamydia, HPV, Herpes, or any other blood borne pathogen or sexually transmitted disease? Do you have any active or past infection of HIV, AIDS, Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D, MRSA, VRE, Ebola, Gonorrhea, Syphilis, Chlamydia, HPV, Herpes, or any other blood borne pathogen or sexually transmitted disease? Yes No

If 'Yes' on previous question, please explain.

Questions & Comments

DISCLAIMER & PLACENTA ENCAPSULATION SERVICE AGREEMENT: Your placenta encapsulation specialist (“specialist”) is not a pharmacy, pharmaceutical representative, 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 arts 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 or anxiety, 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 helpful in their postpartum recovery, you are still encouraged to seek appropriate assistance and medical care when necessary. It is always okay to ask for help. Please sign the form to indicate that you have read, reviewed and agree to the preceding information, as well as the following: I have read, understood, and agreed to the above procedures, information, and statements of policy. By signing my name, 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 delivery to the specialist and notifying the specialist of my birth within 72 hours while the placenta is being appropriately cooled and stored. I have honestly disclosed my health history and all pertinent health details and preferences on this form. I understand that it is my responsibility to inform, and I commit to full disclosure of any known blood-borne illness(es) or other health issues that the specialist may become infected by through contact of bodily fluids (specifically maternal and fetal blood and amniotic fluid), such as HIV/AIDS, hepatitis, sexually transmitted diseases, etc. I understand that there is not a medical consensus on dosage for consumption of placenta encapsulation. I understand that it is my responsibility to maintain the correct storage of the placenta when it is delivered back to me and that it is my responsibility to discontinue consuming my placenta if I experience illness or ill effects which I suspect to be a result of consuming my placenta. I am also responsible for discontinuing consumption of my placenta if I become pregnant. 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. I understand and accept all of the terms and conditions in this service agreement, including payment terms, and acknowledge that this Placenta Encapsulation Service Agreement is a legal Document. I understand that by checking “I have read and agree,” below that I am acknowledging receipt of this document and that I am agreeing to abide to the terms and conditions contained in this agreement. Your placenta encapsulation 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. DISCLAIMER & PLACENTA ENCAPSULATION SERVICE AGREEMENT: Your placenta encapsulation specialist (“specialist”) is not a pharmacy, pharmaceutical representative, 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 arts 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 or anxiety, 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 helpful in their postpartum recovery, you are still encouraged to seek appropriate assistance and medical care when necessary. It is always okay to ask for help. Please sign the form to indicate that you have read, reviewed and agree to the preceding information, as well as the following: I have read, understood, and agreed to the above procedures, information, and statements of policy. By signing my name, 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 delivery to the specialist and notifying the specialist of my birth within 72 hours while the placenta is being appropriately cooled and stored. I have honestly disclosed my health history and all pertinent health details and preferences on this form. I understand that it is my responsibility to inform, and I commit to full disclosure of any known blood-borne illness(es) or other health issues that the specialist may become infected by through contact of bodily fluids (specifically maternal and fetal blood and amniotic fluid), such as HIV/AIDS, hepatitis, sexually transmitted diseases, etc. I understand that there is not a medical consensus on dosage for consumption of placenta encapsulation. I understand that it is my responsibility to maintain the correct storage of the placenta when it is delivered back to me and that it is my responsibility to discontinue consuming my placenta if I experience illness or ill effects which I suspect to be a result of consuming my placenta. I am also responsible for discontinuing consumption of my placenta if I become pregnant. 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. I understand and accept all of the terms and conditions in this service agreement, including payment terms, and acknowledge that this Placenta Encapsulation Service Agreement is a legal Document. I understand that by checking “I have read and agree,” below that I am acknowledging receipt of this document and that I am agreeing to abide to the terms and conditions contained in this agreement. Your placenta encapsulation 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 and agree