Placenta Encapsulation Agreement Form
By completing this form you are reserving services with Alecia Smith and The Nurtured Leaf, LLC.  For areas located more than 30 miles from Enumclaw, there will be a small travel fee beginning at $25+.  Please email me if you have any questions at

June Due Dates: FULL
July Due Dates: FULL
August Due Dates: 4 open
September Due Dates: 5 open
October Due Dates: 6 open
November Due Dates: 6 open
December Due Dates: OFF CALL 
January Due Dates: 6 open
February Due Dates: limited availability, early Feb only.  Please email with questions. 
March Due Dates: 6 open

**Please note, if you are a returning client and my calendar is marked full, please reach out to me!
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Client Name *
Phone *
Email *
Mailing Address (Please notify me if this will change between now and your estimated due date.)
Due Date or Baby's Birth Date *
Name of partner or person(s) who may contact me about your placenta
Partner / Contact Person's Phone
Planned Place of Birth
Will this be your first birth?
Have you encapsulated your placenta in the past?
Any health concerns during this pregnancy? Are you currently taking any prescription medications?
Do you know your current GBS (group B strep) status
Have you ever been diagnosed with any of the following bloodborne infectious diseases?
How did you hear about my placenta services? Did anyone refer my services to you?
Placenta Encapsulation Services
All of my Full Service Packages include:
+ Pick up of placenta from birth location and delivery to your home!
+ Fast turnaround time, typically within 48 hours unless placenta was frozen
+ Choice of Preparation Method: Simply Dehydrated or Steamed & Dehydrated
+ Choice of Size 0 Capsules: Clear Vegetarian or Berry Flavored Gelatin
+ Preparation will take place in my dedicated workspace.
Choice of Placenta Encapsulation Package
Encapsulation Methods
Simply Dehydrated Preparation Method //
Raw Foods Inspired Method of Preparation. Also called "RAW" Method. This is the most popular choice of my clients. This method skips the steaming process altogether and the placenta is sliced while still "raw" and dehydrated immediately. The placenta is dehydrated at 160 degrees according to USDA safety recommendations for dehydrating meat. At this temperature, bacteria and active enzymes are destroyed. It is believed that essential hormones are retained and the iron content is made more bio-available using the Raw Method. This method yields a slightly higher number of capsules than TCM. Based on responses from my clients' experiences, this method is the most balancing as it produces both emotionally balancing properties and increased energy. Some indications for choosing the Simply Dehydrated Preparation Method would be: long labor, postpartum hemorrhage or a history of it, desire to increase breast milk and energy immediately postpartum.

Steamed and Dehydrated Preparation Method //
This method is also known as the Traditional Method, Traditional Chinese Medicine Inspired Method, or TCM. It is the oldest known method and follows with the TCM principles and specific needs during the postpartum period. In TCM theory, the process of labor and birth leaves the mother with an open, empty space which is considered very cold or yin. One way to promote healing during this time is to add warm energy via heat, or yang. This method of preparation involves steaming the placenta gently with optional herbs and then dehydrating at 160 degrees. I can add fresh and organic lemon, ginger and cayenne pepper, only if requested. Putting the herbs in the steaming process is thought to bring out the placenta’s natural healing properties. Lemon is thought of as an antiseptic and helps to distribute the placenta throughout the body. Cayenne and ginger are warming herbs and thought to lend their properties to the placenta. The ginger specifically acts as a facilitator for energy and good blood flow. TCM is believed to have tonifying, healing and warming properties. If your placenta has been frozen, this is always the method of choice.
Encapsulation Methods
Would you like any herbs to be added during the steaming process? *(For Steamed & Dehydrated Method only)
Choice of Capsules
Additional Options to add on: (***Please note: These are in addition to what is included in your chosen package)
Choice of Delivery Return Shipping Method (Upon completion of your package, you will receive a text from me notifying you it is ready for shipping.) Please choose your delivery preference.
Entire Agreement
This agreement contains the entire understanding between The Nurtured Leaf, LLC and The Client. It supersedes all prior and simultaneous agreements between the parties. The only way to change or add to this agreement is to do so in writing with all the relevant parties signing provided document.

Upon your signature and payment, The Nurtured Leaf, LLC will reserve the time surrounding your due date on our calendar. For this reason, the encapsulation deposit of $100 is non-refundable, even if the service is canceled for any reason. The $100 deposit is to be paid at the time of signing the Agreement Form.

The Client agrees that a Non-Refundable $100 deposit fee is required at the time of the acceptance of the Agreement Form. This deposit applies to your total placenta services purchase. Remaining balance is due upon pickup of the Placenta to The Nurtured Leaf, LLC for chosen Encapsulation Services. If the remaining balance payment is not paid in full upon delivery for services rendered and products purchased, a 1.5% daily late fee will incur, until the balance is paid in full.

Payment may be made either by cash, check, Venmo or via a credit card. A $35 fee will be charged for all returned checks. A 3% Convenience Fee will be charged for all credit card payments.

Travel time is included in the encapsulation fee for the Full Service Encapsulation Package unless over 30 miles from zip code 98022. Location will be agreed upon during booking and if location is farther than 30 miles, a travel fee of $25+ will be incurred depending on location. If there is a location change after the Agreement Form has been signed and it is out of the 30 mile radius, a fee will be charged.

No refund is given for services canceled. If The Nurtured Leaf, LLC is unable to provide placenta services due to illness or is otherwise incapacitated, all efforts will be made to send a back-up specialist. Contract will then be taken over by the back-up specialist. If The Nurtured Leaf, LLC is unable to provide services and no back up specialist is available, the deposit will be refunded in full. It is The Client’s responsibility to get permission for release of the placenta from care provider. If The Client is unable to obtain the placenta or it is contaminated before release and unable to be consumed for any reason beyond The Nurtured Leaf, LLC's control, there is no refund of deposit. Once the client has called The Nurtured Leaf, LLC to come pick up the placenta, full payment is due. If the placenta was misplaced, not saved by care provider, or unusable; but The Nurtured Leaf LLC is already enroute to pickup, The Client will receive an invoice for $50 and the $100 deposit fee will remain non-refundable.

The Client will notify their care provider during a prenatal visit that they plan to keep their placenta. If they require a release form to be signed for the release of your placenta, they will provide you with one (hospital birth).

The Client agrees to contact The Nurtured Leaf, LLC as soon as labor begins and then again after baby is born. Please contact via text message if after 10pm or before 7am. Pickup hours are between 7 am and 7 pm. As long as The Client has contacted The Nurtured Leaf, LLC by 7 pm, their placenta will be picked up on the same day, otherwise a time will be arranged for the placenta to be picked up the following morning. The Client agrees to keep the placenta in their sight at all times to ensure it does not go to a lab where it could be contaminated by chemicals or other harmful substances rendering it unsafe for consumption. If the hospital must test the placenta, a small piece can be taken off the maternal side and sent to the lab, while the intact placenta is stored properly. The Client agrees to have the double bagged placenta placed in a refrigerator (home birth) or cooler with ice (hospital or birth center), within 4 hours of birth. If The Client has reserved services with The Nurtured Leaf, LLC within 3 weeks of their estimated due date, they will receive a provided placenta transportation kit. The Client is responsible for packing along the provided placenta transportation kit along with them, for the birth. If The Client has reserved services less than 3 weeks of their estimated due date, The Client is responsible for providing a cooler to properly store their placenta in. The placenta should sit out for no more than a maximum of 4 hours at room temperature. Ideally, please place it on ice or in a refrigerator within 1 hour of birth. If The Client is unable to contact The Nurtured Leaf, LLC within 3 days of the birth, The Client should freeze the placenta until they are ready for it to be picked up. A frozen placenta may take additional time to prepare, so that it can be safely thawed. The Client understands that the same post birth care instructions apply to C-Sections.

There are no State mandated regulations in Washington barring placental release or consumption. The place of birth may have policies and may require a release form. The Client is responsible for determining the policy of their birth place during pregnancy and informing the care provider that The Client plans to keep their placenta.

The Client understands the risks of placenta consumption are the same as dining out in a restaurant where the food is prepared for you. Other risks may include: placenta being switched with another placenta that is not The Client’s at the hospital; placenta contamination with chemicals at the hospital pathology laboratory; and contamination during transport (either by hospital or The Client failing to store properly).

The Client acknowledges the following benefits of placentophagia:

• Preventing and lessening the risk of postpartum depression or “baby blues”
• Replenishing iron from blood loss during birth and prevention of post birth anemia in the mother
• Lending a consistent flow of oxytocin (the love hormone) long after the birth euphoria ends
• Provides the HPL hormone to help establish early and healthy milk supply for breastfeeding
• Stabilizes constantly fluctuating hormones post birth
• Replenishes B vitamins and energy that were used during the labor and birth process
• Protection from infection and bleeding due to retained placenta tissue or membranes
• Offers natural pain relief from the labor and birth process via the hormone POEF (placenta opioid enhancing factor)

The Client understands that choosing to encapsulate their placenta is not intended to prevent or treat any physical or mental diseases, ailments or symptoms and that The Client is choosing to consume their placenta for their own personal beliefs, whether it is spiritual or cultural.

The Client acknowledges that The Nurtured Leaf, LLC has provided concrete information about the benefits and risks of placenta encapsulation and has read all included documents. The Client understands that the placenta has been handled and encapsulated according to OSHA and WA Food Safety and Handling standards, has been rinsed with clean water, steamed (if this preparation method has been chosen), dehydrated and put into capsule form in a sanitary and disinfected work space. Upon receiving placenta capsules or other placenta products, The Client waives any and all rights to hold The Nurtured Leaf, LLC and Alecia Smith responsible for any undesired effect of consuming the capsules.

The Client does not hold The Nurtured Leaf, LLC or Alecia Smith responsible or liable for any transport mishap that is beyond their/her control (ex: car accident or detainment). The Client understands that the placenta will be prepared in The Nurtured Leaf, LLC's dedicated workspace and returned to The Client as soon as their chosen package has been completed. Preparation usually takes 2 days.

The Client understands that if they are positive for STD’s, placenta preparation will take place in their home. If placenta is prepared in The Nurtured Leaf, LLC's dedicated workspace, The Client places full trust and acknowledgement that it is being handled in a sanitary and safe environment.

The Client understands that upon receiving placenta capsules and products, The Nurtured Leaf, LLC and Alecia Smith are no longer liable, including but not limited to any other persons ingesting The Client’s placenta.

Alecia Smith/The Nurtured Leaf, LLC is not a licensed medical professional and is not able to diagnose, treat or prescribe for any health condition. Services and fees are for the preparation and encapsulation of The Client's placenta, not for the sale of the capsules. No specific benefits or effects are promised. Any benefits will vary from person to person. Some of the ascribed benefits of placenta consumption are supported by research; however these benefits have not been evaluated or approved by the Food and Drug Administration. It is The Client's responsibility to determine whether using placenta preparations may be of benefit to them.

The Client should always speak to their care provider regarding any questions about health, safety and well-being. Placenta services are not meant to be a replacement for medical advice or prescription medicines. If The Client is experiencing symptoms of postpartum depression, low milk supply, or other medical concerns, The Client should speak to their midwife or doctor.
Please choose your preferred method of deposit payment
If you would prefer a Venmo payment request directly from me, please leave your username below.
I understand the $100 deposit is non-refundable if placenta services are not rendered, and that it covers the costs of the transportation kit and time being on call. This deposit reserves services, and guarantees The Nurtured Leaf's availability. I agree to the entire preceding agreement by signing my name below.
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