Placenta Encapsulation Client Intake Form
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Email *
Name (Last, First) *
Due Date *
Street Address *
City, State, Zip *
Phone Number *
Best method of contact *
Will you be using a doula or birth attendant? *
Doula's Name & Number (if applicable)
Is this your first pregnancy? *
How has this pregnancy gone so far? Any complications? Please explain? *
Do you have a history or anxiety or depression? If so, please explain. *
Planned place of delivery *
If hospital, which one?
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Name of OB or Midwife *
Have you told your care provider of your plan to keep your placenta? *
If so, was he/she supportive?
Do you have a latex allergy? *
Do you or your partner have any infectious diseases such as HIV, AIDS, Hepatitis, Herpes, etc? *
Are you able to provide blood work confirming this? *
If so, please list below
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 non-refundable $100 deposit is required and due upon booking.
Payment is due in full at or before placenta pick-up.
Contract cancellation may take place at any time prior to placenta pick-up, with no fees or penalties. Your deposit will still be retained if your due date is within 4 weeks of cancellation.
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. This is EXTREMELY important
Place someone at your birth in charge of the placenta. This can be a friend, family member, doula, etc. The hospital may require that the placenta be removed from the premises immediately or within a short time-frame. If you are not prepared and your specialist cannot get there within specified time frame, you can risk losing the placenta.
It is not your specialists responsibility to ensure that your placenta does not leave the hospital in time, should hospital staff give a time-frame.
Know your rights to your placenta and be prepared to assert yourself should those rights be challenged.
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 *
A copy of your responses will be emailed to the address you provided.
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