Sacred Root Placenta Encapsulation
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Mother's Name *
Your answer
Phone Number *
A number that can receive text messages
Your answer
Home Address: *
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Email Address *
Your answer
Estimated Due Date *
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Are you expecting more than 1 baby? If yes, How Many? *
Your answer
Name/Address of Birth Location *
Your answer
Any pregnancy complications so far? If Yes, Please Explain *
Your answer
Is your baby a *
Have you talked to your caregiver about your plan to keep and use your placenta? *
Your answer
Why have you chosen to use your placenta for postpartum benefits? *
Your answer
How did you find out about Sacred Root? *
Your answer
Do you have any Sexually Transmitted Infections or bloodborne pathogens that you know of? *
Your answer
Do you have any food allergies? *
Your answer
Would you like keepsakes? *
Art keepsakes are included in your package however, I realize not everyone would like them. Please let me know if you would like a keepsake made out of your baby's umbilical cord and/or an art print made by pressing paper onto your placenta. You can see examples of these on my site.
Which Package would you like? *
Both packages include Pickup & Delivery, placenta print and cord keepsake and a nursing photo if you' wish.
I (Mother) understand and acknowledge that in accordance to the Florida Drug and Cosmetic Act, choosing to encapsulate my placenta is not intended to prevent or treat any physical or mental diseases, ailments or symptoms, and that I am choosing to consume my placenta due to my personal beliefs. I also understand the my placenta specialist is not a doctor or pharmacist and is acting as a personal chef. *
Sign (type) full name here
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Add-On's
Items to add on to your package for an additional cost
I acknowledge that Cass Martinez and Sacred Root Birth Services has provided me with concrete information about both the benefits and risks of placenta encapsulation, and have read all included documents. I understand that my placenta has been handled and encapsulated according to OSHA and Florida Food Safety and Handling standards, and has been cleaned, cooked, dehydrated and put into pill form in a sanitary and sterile work space. Upon receiving my placenta capsules from Cass Martinez and Sacred Root Birth Services, I waive any and all rights to hold the specialist responsible for any undesired effect of consuming the capsules. I understand that I am choosing to have the specialist encapsulate my placenta in her home. *
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I understand that upon receiving the pills, Cass Martinez and Sacred Root Birth Services is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules. *
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I understand that in most cases turn around is 24 hours but in some cases depending on schedules, turn around can be 72 hours. *
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PLEASE NOTE: The information provided to you by Cass Martinez and Sacred Root Birth Services has not been evaluated by the Food and Drug Administration. The services I offer are not clinical, pharmaceutical, or intended to diagnose or treat any condition. Families who choose to utilize the services on this page take full responsibility for using the remedies at their own risk. *
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