Long Island Placenta Services Intake and Contract
Thank you for choosing Long Island Placenta Services (LIPS) for your placenta preparation. We service Nassau, Suffolk and other closely surrounding areas in New York. Upon receipt of this form, you will receive an email from us within 24 hours. We do not require a deposit. If you are using a cell phone to complete the form, please note that sometimes it does not work properly. If you do not receive an email from us within 24 hours, we may not have received it.

Please know that all information will be held in confidence.

If you are dropping off to us, we have two locations for drop off and pick up on Long Island: Farmingdale and East Islip. If you do not receive an email confirmation within 24 hours after submitting this form, please resubmit or contact us. You can reach us with questions or comments at 631-574-2250, visit our website at www.liplacenta.com, or email us at liplacenta@optonline.net.

Thank you for choosing Long Island Placenta Services.
What is Placenta Encapsulation?
Placenta encapsulation is the process of preparing the mother’s placenta after the birth of her baby(ies) by dehydrating and then ground and placed into capsules for the mother to ingest as she sees fit. The ingestion of the placenta is known as “placentophagy.”
There are two methods of preparation: Traditional Chinese Method (TCM) and Raw. Please see below for the detailed descriptions of each.

Studies show* that the placenta is extremely nutrient rich, high in iron, protein, vitamins and minerals, including vitamin B6 and of course, mother’s own natural hormones, making it perfectly suited for each individual.
Experts agree* that ingesting the placenta slowly reintroduces the hormones into the mother’s system and may ease hormonal fluctuations and the side-effects that come with them.

Your baby's placenta will be treated with honor and respect during the preparation process. We provide the highest standards of safety and service. Long Island Placenta Services conform to guidelines for food preparation and safety protocols.
Client Information
Client Name (First and Last) *
Your answer
Partner Name (First and Last) *
Your answer
Due Date *
MM
/
DD
/
YYYY
Where will you be giving birth? *
Required
If other, please specify
Your answer
Care Provider's (Doctor or Midwife) Name *
Your answer
Doula's Name (if applicable)
Your answer
Your home address *
Your answer
Phone number *
Please include home and cell of both you and your partner
Your answer
Email Address *
Your answer
Your date of birth *
MM
/
DD
/
YYYY
Do you have any allergies to: *
Check all that apply
Required
Are there any other allergies that we need to be made aware of? *
Your answer
Do you have or have you ever had: *
Check all that apply
Required
GBS Status (group b strep) *
Required
Have you taken any medications during pregnancy? *
if yes, please specify
Your answer
Traditional Chinese Method (TCM) vs. Raw Method
There are two primary methods of preparation for encapsulating placenta: the Traditional Chinese Method (TCM) and the Raw method. Each method is appropriate for consumption by all mothers.

TCM:
TCM is the oldest-known and most commonly-used recipe for postpartum placenta preparation. The hallmark of this method is that the placenta is steamed during processing. In TCM theory, the process of labor and birth leaves a lot of open, empty space, which is considered very yin, or cold. Therefore, one major way we can promote healing during the postpartum period is to add yang energy, or heat. We incorporate steam, lemon, ginger and hot pepper into the preparation. These are included in the steaming water only, and are not incorporated into the capsules. The final result is warming, toning, and nourishing for the postpartum period.

Raw:
Unlike the Traditional Chinese Method preparation of the placenta, we do not steam the placenta during the raw encapsulation process. We forgo the steaming to save the vital nutrients and hormones that may be depleted once the placenta has heated*. In our experience, placentas prepared using the Raw method yield more capsules. One method is not better than the other. We offer several options for encapsulation and you should choose the method that best suits your needs and preferences. Moms suffering from previous anxiety may want to consider the TCM for its gentler properties.

In addition to encapsulation, we offer several other placenta preparations (listed below).
Encapsulation Options and Fees *
Please check one
Required
Cord Keepsake *
Please check one
Required
Raw Cube Preparation
Consuming the placenta in its raw state is most beneficial during the immediate postpartum period for internal wound healing, lessening postnatal bleeding and mood balancing.

When choosing a raw preparation for smoothies, LI Placenta Services will prepare and freeze cubes for immediate or future use. These cubes can then be put into fruit smoothies and consumed.
Raw Cube Options -- if you are GBS positive this option isnt available to you *
Please check one
Required
Placenta Prints
Placenta prints are unique works of art that display the size, shape and general appearance of your placenta and show why the placenta is often called "The Tree of Life."

When creating placenta prints, in order to prepare the placenta for consumption, no paints or dyes are used. Prints are done solely with the blood naturally remaining after delivery.The prints are made before the placenta is washed and prepared. They are printed with the natural placenta blood on acid-free artists paper. Some families frame them and display their prints as art or others choose to save them as personal keepsakes.
Placenta Print Options *
Please check one
Required
Placenta Balm
The placenta has long been known to have healing qualities for the skin. Many high-end anti-aging lotions and creams contain "sheep placenta extract" as their special ingredient. We have created a natural and healing balm using your own placenta, custom made for your personal use.

Placenta balm can be used for
~ Cesarian and surgical scars
~ Perineal tears
~ Diaper rash
~ For general healing and skin-care
Placenta Balm *
Please check one
Required
Placenta Tincture
This is a mother tincture, which is processed from a raw piece of placenta and takes about 6 weeks to complete. If stored properly, this can last indefinitely.

This is a great item to have in your natural remedy stash. While the pills work best in the immediate weeks following the birth of your baby, this works great for years to come. (Times of transition, menopause, hormonal imbalance, and even the common cold)

**Please note: When ordering tinctures, the curing process takes approximately 6 weeks. The finished product will be dropped off or mailed upon completion.
Placenta Tincture Options *
Please check one
Required
Chocolate Placenta Truffles
Your placenta is dehydrated using either TCM or Raw method. It is then ground and mixed into a delicious truffle recipe made from coconut, cacao and pure agave syrup.
Placenta Truffle Options *
Please check one
Required
Delivery Method
Long Island Placenta does not pick up from hospitals outside of Long Island. If you are giving birth on Long Island but reside in Queens please check the option to have your products mailed back to you or you can have someone pick up the finished products. We generally do not deliver products past Nassau County.
Delivery Method *
Please check one -- please note if you are receiving raw cubes for smoothies we can NOT mail back your products
Required
Preparing At Your Home
Preparation of your placenta is a two-day process.

Day 1:
We would need approximately 1 and ½ hours to work on your placenta. Someone needs to be home during this time for us to prepare. Our process time could be delayed if we need to wait until you are home from the hospital to begin. We need a usable, empty sink with ample counter space to work. The dehydrator will need to remain on for at least 12 hours. It must remain undisturbed during this period. This requires counter space with an electrical outlet that is free from disturbance. Our own materials are available, but if you prefer, we can use yours. The equipment that we use include: knife, dehydrator, industrial blender, pot and steamer.

Day 2:
We return the following day to complete the process of encapsulation. This will take approximately 1 and ½ hours. Once again, someone needs to be home during this time.
Preparing At Your Home
Please Initial - only if applies
Your answer
Would you like someone from Long Island Placenta to call you? *
Required
If you would like to pay by credit card, please complete the information listed below. We will NOT charge until we physically have possession of your placenta
Name on card
Your answer
Card number
Your answer
Expiration date
Your answer
CV code (three (or 4 amex) digit number on back)
Your answer
Zip code affiliated with credit card
Your answer
Client Responsibility
It is the client’s responsibility to notify LIPS as soon after the birth as possible (preferably the same-day as the birth itself) to request pick-up or notify of delivery.

Failure to do so may result in delayed placenta preparation and may cause decreased potency of nutrients, hormones, and other beneficial attributes of the placenta(s), and even spoilage of the placenta(s) which would render it unusable for consumption. It is also the client’s responsibility to discuss release of her placenta(s) after her birth from the establishment where she delivers and to ensure proper storage of her placenta(s) in a refrigerator or cooler with the placenta(s) placed on ice until it can be picked up or delivered to LIPS for preparation.

It is also the client’s responsibility to inform LIPS of any known blood-borne illness(es) or other health issues including Group B Strep status.
Client Responsibility *
Please Initial
Your answer
Provider Responsibility
Our responsibilities include maintaining client confidentiality, preparing and returning your products to you within 72 hours of receiving your placenta (typically within 36-48 hours), and upholding the highest standards of cleanliness, safety, and quality of professional placenta preparation services. We commit to being on-call to prepare and deliver your products in a timely manner. Please note that our pick-up and delivery times are generally between 9am and 9pm.
Provider Responsibility *
Please Initial
Your answer
Limitations and Disclaimer
Long Island Placenta Services (hereinafter referred to as LIPS) is not a pharmacy, pharmaceutical representative, holistic practitioner, herbalist, or medical doctor. Benefits of placentophagy are supported by ongoing research but have not been evaluated by the Food and Drug Administration.

Placentophagy, (as it pertains to this contract agreement, is for natural nutritional supplementation and is intended solely for ingestion by the mother who has birthed the placenta(s) and not for her family members, friends, or other individuals, is a natural nutritional supplement and as such cannot be guaranteed to produce specific results. Families that chose to utilize the placenta preparation service take full responsibility of their own health and researching and using placenta remedies.

“This service has not been evaluated by the FDA. The services offered are not clinical, pharmaceutical, or intended to diagnose or treat any condition. Families who choose to utilize these services take full responsibility for their own health and for researching and using capsules.”
Limitations and Disclaimer *
Please initial
Your answer
Release and Storage of your placenta
It is the client’s responsibility to discuss release of her placenta(s) after her birth from the facility where she delivers and to ensure proper storage and labeling of her placenta(s).

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 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 we 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.

Your placenta must not be treated with alcohol, formaldehyde, or any other preservative. If your placenta has been sent to pathology, it will be unusable as sanitation cannot be guaranteed.

It is possible to retain your placenta for release if you have a cesarean birth. Please discuss this with your doctor or midwife, prior to delivery.

Please contact us if you have questions about hospital release.
Release and Storage *
Please Initial
Your answer
"Transportation Kit"
LIPS will ship you an insulated transportation kit -- complete with storage bags and safe handling storage instructions.
Fee for the service is and additional $20.00. Payment is due immediately.
I would like a transport kit with supplies sent to me *
Special Circumstances
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 contact us for further instruction before proceeding. It should be possible to claim your placenta after Caesarean surgery.
Photo Release
From time to time we take photographs of placentas with distinctive features for educational purposes such as peer review. Placenta pictures are shared without any identifying information other than information that may be relevant to the situation (such as "35 weeks" or "twin placentas"). Please initial to indicate that you agree that photos of your placenta may be shared.
Photo Release *
Please Initial
Your answer
How did you hear about Long Island Placenta Services? *
Your answer
Additional Available Services
Did you know ? ....

Long Island Placenta Services are also certified Doulas with over 40 years of combined experience. We offer a full-range of Pre- and Postnatal Support, classes and services including:

* Birth Doula Services
* Postpartum Doula Services
* Breastfeeding class-Taught by an International Board Certified Lactation
Consultant (IBCLC)
* Pumping Basics/Return to Work Class-Taught by an International Board
Certified Lactation Consultant (IBCLC)
* Childbirth Preparation Classes/Lamaze (4 week series)
* Bringing Baby Home: A Survival Guide to the First Six Weeks Class
* In-home Postpartum Lactation Consult with an International Board
Certified Lactation Consultant (IBCLC)
* Infant Care Cass
* Belly Casting

If you are interested in any combination of these services, upon submitting this form, one of our Birth Professionals will contact you with more information.

* This is for information only, if you choose a service below, we will not charge your credit card.
Ala Carte Services *
If you would like information on our other services, please check the ones you are interested in.
Required
Agreement and Signature
* 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 accept the responsibility of gaining possession of the placenta after the birth, handling of the placenta appropriately prior to Long Island Placenta Specialists taking possession of it, and notifying Long Island Placenta Specialists within 24 hours. I also have read this document and understand my responsibilities and full disclosure of medical history.

* 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.
Please sign below *
By typing my name below, as an electronic signature I agree to the above statements
Your answer
*
*Beacock, Michelle "Does eating placenta offer postpartum health benefits?" British Journal of Midwifery July 2012, Vol 20, No 7 pg 466
*Blank MS, Friesen HG. "Effects of placentophagy on serum prolactin and progesterone concentrations in rats after parturition or superovulation." Journal of Reproductive Fertility. 1980 Nov;60(2):273-8
*Enning, Patricia. Placenta :The Gift of Life. Mother Baby Press, 2007
*Kristal, Mark B "Placentophagia: A Biobehavioral Enigma" Neuroscience & Biohehavioral Reviews, Vol. 4, pp. 141--150.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy