Mommy Made Encapsulation Order Form
Email address *
FIRST NAME:
LAST NAME:
EMAIL ADDRESS:
STREET ADDRESS:
CITY:
STATE:
ZIP:
PHONE NUMBER:
DUE DATE:
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BIRTH LOCATION (NAME OF HOSPITAL OR BIRTHING FACILITY):
Who is your Doctor or Midwife?
I WOULD LIKE MY CAPSULES TO BE THE FOLLOWING FLAVOR(S):
I WOULD LIKE TO ADD THE FOLLOWING SERVICE(S) TO MY ORDER:
*if purchasing a placenta print: what color(s) would you like your print?
I would like Mommy Made Encapsulation to post my placenta encapsulation and tag me in it
Clear selection
What is your Social Media name for Facebook and Instagram?
I understand that THE ONLY reason my placenta is unsafe to encapsulate is if I have AIDS/HIV Positive
Clear selection
I understand that a $50 non-refundable deposit is required to confirm my placenta encapsulation
I HAVE THE FOLLOWING ALLERGIES/SENSITIVITIES:
Limitations and Disclaimer: I am not a licensed medical professional and I am not able to diagnose, treat or prescribe for any health condition. Services and fees are for the preparation and encapsulation of your placenta, not for the sale of the pills. No specific benefits or effects are promised. Benefits will vary from person to person. Many of the benefits are well supported by evidence based research; but none have been evaluated or approved by the FDA. (INITIAL BELOW)
Client Responsibility: It is your responsibility to notify me when you are in labor and again as soon as possible after the birth to make arrangements for transfer of your placenta to me. Improperly handled placentas are susceptible to spoilage and all placenta work is done at your own risk​. I understand that the act of ingesting placenta in any form has not been tested, nor approved by the FDA, and I ingest this at my own risk. Furthermore, I release Mommy Made Encapsulation (Juliane Corona and associates) and its representatives from any liability. (INITIAL BELOW)
It is your responsibility to discuss the release of your placenta with your primary health care provider as well as the facility you will be birthing in. Your placenta may be kept at room temperature for 3­-4 hours following your birth. After that, or as soon as possible, it should be placed on ice or in a refrigerator. (INITIAL BELOW)
Medical Contradictions I certify that I have never been diagnosed with and am not now afflicted with any of the following diseases: ● HIV (INITIAL BELOW)
By entering your name below, you are affirming all of this information to be correct and true:
A copy of your responses will be emailed to the address you provided.
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