Placenta Encapsulation Client Intake Form

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Please complete all applicable fields.

Name (Last, First) *

Due Date *

YYYY

Email Address *

Street Address *

City, State, Zip *

Phone Number *

Best method of contact *

Call

Text

Will you be using a doula or birth attendant? *

Yes

I'm unsure

Doula's Name & Number (if applicable)

Is this your first pregnancy? *

Yes

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 *

Home

Hospital

Birth Center

Other:

If hospital, which one?

Mercy

St. Elizabeth’s

Other:

Clear selection

Name of OB or Midwife *

Have you told your care provider of your plan to keep your placenta? *

Yes

If so, was he/she supportive?

Do you have a latex allergy? *

Yes

Unsure

Do you or your partner have any infectious diseases such as HIV, AIDS, Hepatitis, Herpes, etc? *

Yes

Are you able to provide blood work confirming this? *

Yes

If so, please list below

Package Chosen *

Contentment - capsules only ($300)

Pure Bliss - capsules plus 2 additional add-ons ($375)

No Package - a la carte only

If Pure Bliss, please select TWO of the following

2 tinctures

1 salve

30-minute pregnancy massage

30-minute postpartum massage

Which encapsulation method would you like me to use? *

Gentle (steaming prior to dehydration)

Balanced (no steaming, higher dehydration temperature)

Raw (no steaming, lower dehydration temp)

Would you like a cord keepsake? *

Yes

Would you like a placenta print? *

Yes

Any additional products?

2 oz tincture ($45 or 2 for $70)

4 oz salve ($60 or 2 for $100)

Herbal sitz bath set ($10)

Delivery more than 15 miles from Redding (additional charge applies)

60-minute massage ($100)

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? *

You may use photos of my placenta

You may NOT use photos of my placenta

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