Placenta Encapsulation Form

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After you fill out this order request, we will contact you to go over details and availability before booking service(s). Thank you for your contact!

What is your name? *

Please list your email address *

Please list your phone number *

What is the best way to contact you? *

Phone call

Text

What city do you live in? *

Where do you plan to give birth? *

When is baby's due date? *

YYYY

Have you had your placenta encapsulated before? *

Yes

Have you encountered any complications with your placenta during pregnancy? *

Yes

If yes, please explain

Would you like an iPhone photo of your placenta before it is prepared? *

Yes

How did you hear about Mob-ility? *

Questions you have

Any extra information about you, your birth, etc...

Liability Agreement:

I understand and acknowledge that choosing to encapsulate my placenta is not intended to prevent or treat any physical or mental illness, ailments or symptoms and that I am choosing to consume my placenta for my own personal benefits, whether it be spiritual or cultural.

I waive any and all rights to hold the placenta specialist responsible for any undesired effects of consuming the capsules. I do not hold my placenta specialist responsible or liable for any transport mishap that is beyond their control and understand that I am choosing to have my placenta encapsulated in their home. I put trust and faith that my placenta specialist has been training correctly to prepare placenta remedies.

I understand that upon receiving the pills, my placenta specialist is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules.

Agree

Disagree

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