Placenta Encapsulation Registration Form

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* If you are ready to register, please submit this form and I will respond shortly.

* If you still have more questions, or need to reach Meriah urgently, please call 442-363-2880 or placentaservice@gmail.com or see MamaLovePlacentaEncapsulation.com

* Try to register in advance so you have time to get instructions, guidance, and time to prepare (even though I accept clients at any stage).
*** This information you provide will be kept confidential, between you and Mama Love Placenta Encapsulation/Meriah Davis.

Mother's Full Name *

Due Date *

YYYY

Scheduled C Section Date?

YYYY

Mother DOB

YYYY

Partner/Birth Partner's Name

Phone Number *

Email *

Home Address (for capsule drop off)

Where are you planning to give birth? Or did you already give birth?

Who is your care provider?

Sex of Baby

Male

Female

Multiples

Clear selection

Please select which applies to you.

This is my 1st baby/birth

This is my 2nd baby/birth

This is my 3rd, 4th, 5th+ baby/birth

Clear selection

Do you have any infectious diseases, such as HIV/AIDS, Hepatitis? Active Lyme? *

Yes

Maybe

Please list any infectious diseases you have or may have.

Please list any complications you are experiencing with this pregnancy.

Please list any medications you have been taking during this pregnancy.

Which preparation method do you prefer? For more info please see: https://drive.google.com/file/d/14dUl3qZmynMUp7v6V9EgG-xml82W-uL5/view?usp=drivesdk

SEMI RAW- Not truly "raw" since it will be dehydrated at 160 degrees. Traditionally "raw" food is heated no higher than 118 degrees.

TCM HEATED- Placenta steamed for a few minutes before it goes in the dehydrator.

Half and Half (additional $5)

Clear selection

I am interested in the following along with my Placenta Capsules at no extra charge. (Check all that apply). Free with encapsulation service.

Placenta Tincture (to use after 6 weeks and will be good for many years). More info: https://docs.google.com/document/d/1VxH0y_QQkH_wsinlD7ZbpQc6DaXFKVmCKu2OVwVZlZo/edit?usp=sharing

Umbilical Cord Keepsake. Cords are perfectly imperfect as they are all unique and may change shape after dehydration

Natrual Print with blood. Prints are perfectly imperfect just like placentas

Placenta Print. Food dye applied to placenta and pressed to water color paper. They are perfectly imperfect just like placentas

PeriSpray- soothing spray for perineum. Distilled water + Lavender + Frankincense Essential Oils

Ebook- Essential Oils for New Moms By Meriah Davis

Raw pieces of placenta (thumbnail size, not encapsulated). For blended soups or smoothies (frozen, for you to blend in).

I experienced the following after one or more of my previous births. (Check all that apply).

Challenging Physical Recovery

Challenging Emotional Recovery

Baby Blues

Post Partum Depression

Low Milk Supply

Post Partum Anxiety

No problems

I'm not sure

Other:

Is there anything you would like to share with me about your previous postpartum recovery/ recoveries?

Why are you choosing to ingest your placenta? What benefits are you looking forward to?

Will you be needing a referral to any other services?

Anything else?

How did you find Mama Love Placenta Encapsulation?

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