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 Phone Number
Partner's Phone Number
Anyone supporting you during the birth or I can speak too about the placenta when you aren't available
Estimated Due Date (EDD)
Your Email Address
At Birthing Center
Name of Hospital or Birthing Center
Please include full name. Ex) Kaiser Permanente- Downey
Are you expecting twins?
Identical Twins (One Placenta)
Fraternal Twins (Two Placentas)
Just one baby
Are you expecting?
We are expecting a baby and a surprise!!
Where would you prefer the encapsulation process take place?
Your Home (Placenta Specialist)
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.
Herpes- outbreak present
This address will be where you want me to deliver the completed placenta capsules.
What services would you like to be prepared for you?
Placenta Encapsulation (Traditional Chinese Method Inspired/Basic Heated)- $300
Placenta Encapsulation (Raw Method)- $300
Umbilical Cord Keepsake (Included with ALL encapsulations)
Placenta Broth (Included with Encapsulation- Basic Heated Method)
Placenta Smoothies- $30 (Organic ingredients used only)
Placenta Print- $20
Placenta Tincture- $40- (Mason Jar Size)
Placenta Salve- $40
Are you allergic to any of these items?
Please check all that apply
Are you interested in a postpartum visit 2 to 4 weeks after your capsules are delivered?
Phone Call Check-In
Do you have any questions relating to encapsulation that I can help you with?
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?
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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