Placenta Encapsulation Registration
Welcome to Ember Birth Services! Please complete the information below. Once your registration is received, you will receive an invoice for the amount in full. Once your payment is received, you will receive an email with placenta storage and pick up instructions. Please read all of the details below.
Personal Information
Name *
Phone Number *
Address *
Email *
Alternate Contact *
Alternate Contact's Phone Number *
Estimated Due Date
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DD
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YYYY
Where are you planning on delivering?
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For your safety and ours please answer honestly. Do you have any of the following? Hepatitis, Herpes, Chlamydia, Gonorrhea, HIV, HPV, MRSA.
Which services are you interested in? *
Required
A cord keepsake is included in your package. This is optional. Would you like a cord keepsake?
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Photos of your placenta or placenta products may be taken for educational, promotional, or record keeping purposes. No identifying information will be shared under any circumstances. If you would like a copy of any photographs taken, please note this request:
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General Information and Policies
Please type your initials in the provided spaces to indicate that you have read and agree to the following information:
Call or text message 505-417-3557 within 1-2 hours after the birth to arrange a time to pick up the placenta. We pick up 24/7/365 with appropriate notice. We will deliver the products within 48-72 hours after pick up. Initial Below: *
Following the birth, your placenta must be placed in a sealed container or double ziplock gallon-sized bags and labelled with your name. It must be put on solid ice that is replaced every two hours or in a placenta specific refrigerator. You are responsible for the safe handling and appropriate storage of your placenta prior to pickup by the specialist. Initial Below: *
Permission is granted for your specialist to transport your placenta for preparation and delivery of completed capsules. Your placenta will be handled and encapsulated according to OSHA, universal precautions and Food Safety and Handling standards. Your placenta will be cleaned, steamed (if indicated above), dehydrated and put into capsule form in a sanitary and disinfected work space. Encapsulation and delivery generally takes 1-2 days for a refrigerated placenta. Initial Below: *
Payment is due in full upon the receipt of your invoice, which will be emailed to you upon completion of this registration. There is a non refundable $50 processing fee. If you cancel after the encapsulation process has begun, no refund will be given. If the placenta is unable to be encapsulated (ie. Infection in labor, placenta sent to Pathology Dept., not stored as outlined above, etc.), please reach out for information regarding your options. Initial Below: *
Placenta Encapsulation is intended solely for ingestion by the person who has birthed the placenta(s). Initial Below: *
I agree that I am paying for the encapsulation service only, which is not intended to diagnose or treat any condition. Your placenta specialist makes no guarantee as to capsule efficacy, but does guarantee the highest quality of service. No refunds for services will be given.
I have read, understood, and agreed to the above procedures, information, and statements of policy. By signing my name below, I accept the responsibility of gaining possession of the placenta after the birth, handling and immediate cooling/storage of the placenta appropriately prior to the specialist taking possession of it, and notifying the specialist of my birth within 1-2 hours. I authorize the release of my placenta to my specialist and I authorize transportation of my placenta for preparation. I have honestly disclosed my health history and preparation preferences on this form. Upon receiving my completed placenta capsules, I waive any and all rights to hold my specialist responsible for any undesired effect or differing benefits of consuming the capsules. SIGN BELOW:
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