Estimated Birthing Date:
Address of Birthing Location: (Hospital/home/birth center)
Have you notified your health care provider you want to keep your placenta?
Is this your first pregnancy?
Describe any complications with pregnancy or history of STD:
Pick up of Placenta
I would like my placenta picked up from birth location.
I will arrange drop off of my placenta to encapsulation location.
Delivery of Encapsulated Placenta Pills:
I would like them delivered to my home.
I would like to pick them up at the place of encapsulation
I am excepting:
Multiples ($25 Fee)
I have specific requests for my placenta and/or capsules and they are:
I accept full responsibility for my health and voluntarily complete this Acknowledgment and Waiver of Liability Form. I certify that I am seeking the service of placental encapsulation from Amy McCoy of Blissful Birth ans Beyond, which I fully understand are not medical diagnoses or treatments or substitutes for medical diagnoses or treatments. I certify that with respect to any medical conditions or concerns I may have, I have been advised to consult with my personal care physician.
I understand that placental remedies have not been FDA registered or approved and may not beoffered by practicing physicians (allopathic or otherwise) and which may be considered experimental.
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