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Placenta Encapsulation Intake Form
Starting at $195, add-ons extra. 
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First and Last Name  *
Email *
Phone Number *
Preferred method of contact? *
Home Address *
How did you hear about our services? Please check all that apply. 
Are you a Mountain Time Midwifery or Welsh & Womb Client? 
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Planned Birth Location (Address) *
Estimated Due Date *
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DD
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YYYY
Preferred Placenta Processing Method *
Capsule Choice *
Additional options: +$5 per blend.  *
Required
Would you like to add a tincture? If yes, what size? *
Required
Cord Keepsake (Free if in combination of encapsulation/tincture, $20 on its own.) *
Placenta Print (+$5 if in combination of encapsulation/tincture, $10 on it's own) *
Any Additional Questions? 
Contract Agreement

Placenta encapsulation is the process of preparing the Mother's placenta after the birth of her baby by dehydrating, powdering and encapsulating and/or adding a small piece of the placenta in alcohol to create a tincture. All processes are done with respect and a blessing to honor the placenta, and done in a sanitary environment, Daphne Welsh follows proper food safety standards and universal precautions guidelines.
 
Ingestion of the placenta is thought to reintroduce beneficial hormones, proteins, and other nutrients that may have been lost during labor and childbirth. It may restore emotional and physical balance and prevent or lessen the risk of "baby blues" that may lead to postpartum depression, It is said that it may increase milk production, shorten healing time, restore iron levels, and provide overall well-being during the 4th trimester. 

Client Responsibility: 
A $55 retainer fee is required to hold your due date for me to be on call and is due at the time this form is submitted. I will be on call for your birth from 37-43 weeks of pregnancy once retainer fee is received. The entire payment is due by 38 weeks of pregnancy. If the full payment is not received Daphne Welsh will pick up the placenta but will not begin processing until full payment is received. 
It is the clients responsibility to inform Daphne Welsh within 24 hours of birth, ideally immediately postpartum, so I may arrange to pickup the placenta. Once the placenta has been picked up, as long as payment has been received, it will be processed and returned to you in no more than 72 hours (although please note I am a birth worker and on call 24/7, so I will do my best to return it to you within that 24-48 hour immediate postpartum timeframe). 
For the placenta to be processed, it must be kept fresh. A placenta can be kept at room temperature for no more than 3-4 hours, on ice for no more than 24 hours, in a refrigerator for no more than 3 days, and in a freezer for no more than 6 months. There are very few reasons a placenta cannot be processed, these reasons are most commonly; a placenta being taken to pathology or an active infection in mother or baby. Meconium and GBS+ results have not been confirmed to be risk factors for encapsulation and ingestion.

Refund Policy: 
I refund completely for maternal or fetal loss of life. 
I refund all but the retainer of $55 for placenta's that are unable to be ingested. I do not refund for placenta's that are not kept fresh due to negligence. 
If placenta pick-up or drop-off is outside of Salt Lake or Davis County a $10 service fee is added to both pick-up or drop-off ($20 if both are outside these counties) If you wish to waive this fee, please pick-up or drop-off at my Salt Lake location. If I attend your birth, pick-up and drop-off fees are waived. 

Disclaimers:
Welsh and Womb is a not licensed medical professional, I am not allowed to treat, diagnose or prescribe for any health condition. No specific benefits or effects are promised. Benefits may vary from person to person. Benefits from placenta consumption and herbal blends are supported by a small, but growing body of research and client success stories; however these benefits have not been evaluated or approved by the United States Government or the Food and Drug Administration. It is your responsibility to determine whether placenta consumption may be beneficial to your postpartum journey.   

Cash and Venmo accepted. 
Venmo: @d-counter

I have read, understood, and agree to the above information. I accept the responsibility of gaining possession of my placenta, and notifying my placenta specialist within 24 hours of my birth. I understand the importance of appropriate handling and storage of the placenta. By signing below I authorize Daphne Welsh to prepare my placenta for my own personal use.

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