(if at a hospital please specify which one)

for this pregnancy

If so please list below

Please check all that apply

If using one

DISCLAIMER  {Placenta preparation, as offered by Long Island Born is not clinical, pharmaceutical, or intended to diagnose or treat any condition. Placenta preparation is not meant to be a replacement for medical advice, medical care or medicine. Services and fees are for the preparation and encapsulation of your placenta and not for the sale of the pills. Families that choose to utilize the placenta preparation services take full responsibility of their own health and for researching and using placenta remedies. Long Island Born does not make any guarantee as to the efficacy, but does guarantee the highest quality of service. Benefits of placentophagy are supported by ongoing research but have not been evaluated by the FDA.} (Please initial below )

Whether birthing at home or in a hospital, please ensure that your placenta is kept fresh. It can remain at room temperature for 3-4 hours following the birth. After that it should be refrigerated or otherwise kept cool. If you are practicing some form of delayed cord cutting beyond the 3-4 hour window or lotus birth, please contact me. If it is going to be more than 72 hours before the placenta can be prepared, it should be frozen. (A frozen placenta will take somewhat longer to prepare since I prefer to gently defrost it prior to preparation.) You can prepare your placenta for transport by placing it in 2 large ( gallon size), freezer strength zip-lock bags, then into a cooler or large covered bowl or bucket with ice/ice packs or into a refrigerator. ~~~ It is important to note that there may be circumstances under which your placenta can not be used. Significant abnormalities of the placenta may necessitate your doctor or midwife sending your placenta to Pathology for further examination. Other conditions, such as signs of infection in the mother during labor, may mean that consuming your placenta will not be beneficial to you. If in doubt I will consult with you before proceeding. It should be possible to claim your placenta after Cesarean surgery. ( Please initial)

It is your responsibility to notify me after the birth (ideally within 24 hours) to make arrangements for pick up, drop off, or for me to come to your home. Failure to do so may result in delayed placenta preparation and encapsulation and may cause spoilage of the placenta which would render it unusable for encapsulation. ~~~ It is your responsibility to discuss release of your placenta from the hospital where you give birth and to ensure proper labeling and storage of your placenta in a refrigerator or cooler with the placenta placed on ice until it can be picked up or delivered for preparation and encapsulation. Your placenta should not be treated with alcohol, formalin, or any other preservative. Please contact me if you need assistance with hospital release. You should contact the hospital directly, not just your doctor or midwife. (Please initial.)

Please choose all that apply

for vegans and vegetarians

I have read, understood, and agreed to the above procedures, information, and statements of policy. By typing my name below, as an electronic signature, I give my consent to release my healthy placenta to Long Island Born for the purposes of encapsulation. I accept the responsibility of gaining possession of the placenta after the birth, handling of the placenta appropriately prior to Long Island Born taking possession of it, and notifying Long Island Born of my birth within 24 hours. If selecting Off-Premises services, I authorize the release of my placenta to Natural Light Photography & Birth Services and I authorize Long Island Born to transport my placenta for preparation. * Please type your name, as your electronic signature, to show that you have read all of the above information and that all of the above information submitted by your is true and accurate.