Placenta Encapsulation Intake Form
This intake form will help us get your encapsulation and placenta services ready to go! Please fill it out completely to better serve you! Thank you!
Mother's Name *
Mother's Phone Number *
Partner's Phone Number *
Partner's Name *
Anyone supporting you during the birth or I can speak too about the placenta when you aren't available
Estimated Due Date (EDD) *
MM
/
DD
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YYYY
Your Email Address *
Birthing Location *
Name of Hospital or Birthing Center *
Please include full name. Ex) Kaiser Permanente- Downey
Are you expecting twins? *
Are you expecting?
Clear selection
Where would you prefer the encapsulation process take place? *
Have you tested positive to any of the following? *
We follow strict OSHA and Bloodborne Pathogens Handling of the placenta with ALL placentas. Please disclose which one you've tested positive for safety practices.
Required
Your Address *
This address will be where you want me to deliver the completed placenta capsules.
What services would you like to be prepared for you? *
Required
Are you allergic to any of these items? *
Please check all that apply
Required
Are you interested in a postpartum visit 2 to 4 weeks after your capsules are delivered? *
Do you have any questions relating to encapsulation that I can help you with?
Follow Up *
Please check one of the following in order to proceed with placenta encapsulation services. Do you prefer to be reached by email, phone call, or text message?
Required
Liability Disclaimer *
The information on this page has not been evaluated by the Food and Drug Administration (FDA). The Services offered by Womb Roots Doula & Placenta Services are not clinical, pharmaceutical, or intended to diagnose or treat any condition. Womb Roots Doula & Placenta Services is not a midwife, medical doctor, herbalist, and or pharmacist. Families who choose to utilize the services on this page take full responsibility of their own health and for researching the benefits. Placentophagy is still being tested and researched. By submitting this form, you agree Womb Roots Doula & Placenta Services to NOT be held liable. Upon receiving my placenta capsules or any other placenta services, my placenta specialist is no longer liable.
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