Placenta Client Intake and Contract
We look forward to providing encapsulation services for you! If you have any questions, please feel free to email us at or call/text at 720-336-WOMB (9662). We would be happy to discuss any concerns, describe our process, or offer any other insight you would like.
Client Information
Client Name *
Your answer
Partner Name
Your answer
Client Email *
If you have a gmail account, this would be preferred, as we share documents via Google Drive.
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Partner Email
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Client Phone *
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Partner Phone
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Home Address *
Your answer
Estimated Due Date *
My baby is already born.
Birth Place *
Your answer
Client Responsibility
By submitting this form, I understand that it is my responsibility to:
~ Provide my blood work with HIV and Hepatitis B status to These tests are typically performed in the panel done in early pregnancy.
~ Discuss my intentions to keep your placenta with my care provider and birth place.
~ Research delayed cord clamping and discuss my decision with my care provider.
~ If possible, call (7am-10pm) or text (anytime) 720-336-WOMB when birth begins to let us know my placenta will be here soon.
~ Call (7am-10pm) or text (anytime) after birth. My placenta will be picked up during more "normal" daytime hours. If I do not get a response to a text within an hour of normal business hours, I will call. Occasionally, text messages do not create a notification and my encapsulation specialists have every intention of communicating.
~ Keep my placenta cool and clean until we arrive. I will bring a cooler; I can use the hospital's ice in zip-top bags to avoid having to worry about my ice packs being cold when they are needed. I understand that failure to do so will make encapsulation unsafe.
~ I will not allow my placenta to be sent to the pathology department. If necessary, a piece can be cut and the remainder will stay with me.
~ Make payment arrangements with Balanced Birth Services. I may send PayPal to and/or pay upon pick up (cash, check, or credit card).
Preparation Method *
Please choose one:
Type of Capsules *
Additional Products
Dietary Specifications
We enjoy providing our clients with these free gifts:
~ Print: The fetal side of the placenta looks like a tree, which is very fitting. This is a simple keepsake for your baby's first "friend" in the womb.
~ Cord Keepsake: We can dehydrate the cord in a spiral or other shape. This can be used as part of a blessingway, it can be buried as part of a growing up ceremony, or can be kept as a reminder of the strong connection between mother and child.

I understand that some situations and/or birth places have practices that make these gifts impossible.

Special Requests/Notes:
Do you want more raw or steamed for half-and-half? Would you like us to try for a specific design for your cord? Would you like multiple types of capsules? Do you have any other special requests? We're happy to accommodate!
Your answer
Returning Students/Clients:
Total Investment: *
Your answer
By submitting this form, I acknowledge:

Balanced Birth Services cannot process the placenta from a HIV or Hepatitis B positive mother with our tools. We would be happy help mothers who are HIV or Hepatitis B positive by teaching her how to process her own placenta in her home and providing the consumable materials needed. We strongly feel every mother should be able to enjoy the benefits of placenta encapsulation.

Balanced Birth Services cannot be responsible for your placenta when it is not in our possession.

Balanced Birth Services cannot encapsulate a placenta that has gone to pathology.

Balanced Birth Services not practice medicine; we do not diagnose or treat disease. The FDA has not evaluated placentophagy and Balanced Birth Services makes no claims or promises as to its efficacy.

Families who choose to use these services are assuming all responsibility and will not hold Balanced Birth Services liable.

Photo Release
I have read and understand the terms of this placenta client contract with Balanced Birth Services. (Digital Signature) *
Your answer
Date of Agreement *
Payment Plan *
How did you hear about Balanced Birth Services?
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