Client Intake Form
Please complete all applicable fields.
Email address *
Name (Last, First) *
Your answer
Due Date *
MM
/
DD
/
YYYY
Street Address *
Your answer
City, State, Zip *
Your answer
Phone Number *
Your answer
Best method of contact *
Will you be using a doula or birth attendant? *
Doula's Name & Number (if applicable)
Your answer
Is this your first pregnancy? *
How has this pregnancy gone so far? Any complications? Please explain? *
Your answer
Do you have a history or anxiety or depression? If so, please explain.
Your answer
Planned place of delivery *
If hospital, which one?
Name of OB or Midwife *
Your answer
Have you told your care provider of your plan to keep your placenta? *
If so, was he/she supportive?
Your answer
Do you have a latex allergy? *
Do you or your partner have any infectious diseases such as HIV, AIDS, Hepatitis, Herpes, etc? *
If so, please list below
Your answer
Are you able to provide blood work confirming this?
Package Chosen *
If Pure Bliss, please select TWO of the following
Which encapsulation method would you like me to use? *
Would you like a cord keepsake? *
Would you like a placenta print? *
Any additional products?
I take photos of your placenta for record keeping purposes. These photos are available to you at any time. With your permission I may use these photos for marketing, advertising, education, peer review or promotional purposes in print or online. Identifying information will not be shared under any circumstances. Do you give permission for photos of your placenta to be used as described above? *
Payment Policies *
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A $100 deposit is required and due no later than 3 weeks prior to your due date.
Payment is due in full before or at placenta pick-up.
Contract cancellation may take place at any time prior to placenta pick-up, with no fees or penalties.
If cancellation takes place after placenta has been picked up or specialist has arrived for in-home preparation, but before preparation begins, a $50 travel fee will be retained. Specialist will return placenta upon request.
If cancellation takes place after preparation has begun, no refund will be given even if client chooses not to take delivery of finished product.
For all births: *
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Talk to your care provider during a prenatal visit about your intended birth place's policies in regards to releasing the placenta.
Call or text your specialist as soon as you know you're in labor.
Call or text your specialist after the birth to arrange a time for placenta pick-up.
The placenta must be refrigerated or chilled within 4 hours of delivery.
Placenta pick-up is guaranteed within 12 hours of delivery, unless other arrangements have been made by the client.
If you're unable to call or text within 4 days of the birth, freeze the placenta until you are ready for pick-up.
Preparation takes 24-72 hours for a refrigerated placenta, a frozen placenta may take additional time to allow for it to be safely thawed.
For planned hospital deliveries AND unplanned hospital transports: *
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Be aware of your rights to your placenta. It belongs to you and you are under no obligation to explain your reasoning for keeping it.
Remind your care providers upon arrival that you plan to take your placenta and remind them again once it's delivered.
Sign any required forms and have them placed in your file.
Do not let the placenta out of your sight or leave your room.
If the medical staff requests to take the placenta to pathology, you have every right to say no. However, there is a way to make everyone happy. You can simply let them know that they may remove a small piece from the placenta (while in your room with you), and leave the remainder with you.
A placenta sent to a hospital's pathology lab cannot be encapsulated.
The hospital will provide a lidded sterile container--and ice upon request--for your placenta.
The container must be labeled with your name before I pick it up.
The placenta can remain at room temperature for 3-4 hours following the birth. Refrigerate or put it on ice as soon as reasonably possible. Improperly handled placentas are susceptible to spoilage.
Be prepared with an ice chest just in case.
Have a plan for a friend, family member, doula, or other support person to transport the placenta from the hospial. On occasion, the hospitals ask that the placenta be removed immediatley or in a short time-frame, and your specialist may not be able to get there in time.
I understand and acknowledge that in accordance to California law, choosing to encapsulate and/or consume my placenta is not intended to prevent or treat any physical or mental diseases, ailments, or symptoms and that I am choosing to consume my placenta for my own personal beliefs, whether it be spiritual or cultural. I also acknowledge that there are no statewide regulations preventing me from obtaining and encapsulating my placenta in my home. I acknowledge that my specialist has provided me with concrete information about both the benefits and risks of placenta encapsulation, and that I have read all included documents. I have disclosed to my specialist my STD status. I understand that my placenta will be handled and encapsulated according to OSHA and California Food Safety and Handling standards, and that it will be cleaned, cooked, dehydrated, and put into pill form in a sanitary and disinfected work space. If my placenta is not encapsulated in my own home, I put full trust and acknowledgement that it is being handled in a sanitary and safe environment. I do not hold my specialist or Afterglow Placenta responsible or liable for any transport mishap that is beyond her control (ex. car accident or detainment). Upon receiving my placenta capsules from my specialist, I waive any and all rights to hold them or Afterglow Placenta responsible for any undesired effect of consuming the capsules. I understand that upon receiving the pills, my specialist and/or Afterglow Placenta are no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules. *
Special instructions, comments, or questions *
Your answer
A copy of your responses will be emailed to the address you provided.
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