Placenta Encapsulation Requirements Form

Feel free to contact us with any questions or inquiries (310) 266-8433

In order to reserve your spot for encapsulation, you must read and complete the intake form below. Included with your intake form must be a copy of labs or a letter from your medical provider verifying negative status of HIV, Hep B, and Hep C status.

Full Name *

Partners Full Name *

Phone Number *

Partners Phone Number *

Email Address *

Home Address *

Doula Name *

Baby # *

Estimated Due Date *

Caregivers Name (OB-GYN, Midwife, GP) *

Planned Place of Birth *

Allergies (specifically herbs/food) *

Do you have a history of depression? *

Do you have any transmittable diseases? *

Prior to dehydration I am interested in having my placenta *

What are you looking to experience from the placenta pills? *

I am ok with waiting for my placenta to be processed in the event my primary encapsulator can not process it immediately (unforeseen circumstances, another client has given birth shortly before you). *

I am ok with the encapsulation process taking place in the encapsulator’s home (abiding by OSHA Bloodborne Pathogens Standards and Food and Safety regulations and requirements, providing a sterile environment, etc). *

I understand that the placenta pills I will be taking will not replace the need for pharmaceuticals or psychological help if I have pre existing health concerns or if I begin to experience any health problems and that I will seek medical attention if I begin to experience any acute or unusual physical or mental health problems.* *

I understand payment is collected upon drop off/pick up of placenta before encapsulation. I understand that a deposit of half of the fee will be retained/due if services are cancelled by client after agreement. *

**DISCLAIMER Placenta pills are not intended to cure any type of health disorder or disease. A qualified healthcare provider must be informed if the mother has a history of depression or is showing signs of postpartum depression or psychosis as these require medical attention beyond the scope of the placenta encapsulator. Please be advised that the placenta pills are strictly intended to aid in the support of postpartum recovery and do not replace pharmaceuticals or psychological assistance required to treat any type of health concern.