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Informed Consent for Placenta Encapsulation
Deanna Norris- Student Midwife, Holistic Doula, Placenta Specialist (APPA-C)

The base price for placenta encapsulation is $250. There are optional add-ins/ons available for a small fee, including flavored capsules, steaming additions, placenta prints and tinctures. The options and prices are listed below. There is a required, non-refundable $50 retainer fee to book my services. The remainder due is expected at the time of placenta pickup. I encourage you to have cash, check or card ready for that payment. I will send you an invoice at the time of booking for the full fee where you can pay the retainer fee. You can also pay the balance via the invoice upon pickup. I prefer that you wait to pay in full until the time of placenta pickup, eliminating the potential need for refunds if the placenta is unable to be processed for any reason. There are potential travel fees, and an additional fee for processing in-home vs in my own dedicated space. Those details are listed below as well.

After filling out this form, I encourage you to save a copy of this form for future reference.

Name
Your answer
Phone
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E-mail
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Address
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Contact person for placenta pickup/drop-off:
Your answer
Estimated Due Date:
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DD
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YYYY
Pregnancy #:
Name of Midwife/OBGYN:
Your answer
Intended place of birth
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Where did you hear about our services? *
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Do you have any food OR environmental allergies?
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Are you allergic to latex?
Do you have any of the following:
Do you have any health complications? Are you taking any medications?
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