Placenta Pros Order Form
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Expected date of delivery
Other contact person's name and phone number
Name and address of facility for pick up (hospital, birth center or home birth)
Mailing address for cooler and capsule drop off. (Coolers will be mailed after payment is received as time allows)
Our complimentary pick up area is within 15 miles of the Fort Worth hospital district (76104). In most cases, we are able to hand deliver the completed capsules before hospital discharge. If you live more than 15 miles from 76104, we may mail your capsules to you. (Included hospitals are Texas Health Resources Harris Downtown and Southwest, Baylor All Saints, JPS, Fort Worth Birthing and Wellness Center)
I want more information because I'll need pick up outside your regular service area.
I understand the basic cost of placenta encapsulation is $275. This covers local pick up, your choice of capsules, a dehydrated umbilical cord keepsake, and local delivery. After sending payment, if time allows, a disposable cooler and zip lock bags may be mailed to the client. Otherwise, the client will provide their own cooler which will be returned with the completed capsules. Payment will be made in full prior to pick up. (cash, check, venmo, zelle, paypal, and square payments with a credit card are all accepted)
Which type of capsules would you like? (All capsules are gluten free)
Vegan unflavored (vegetable cellulose)
Standard unflavored (gelatin)
Strawberry flavored (gelatin)
Orange flavored (gelatin)
Mint flavored (gelatin)
I would like a mix of flavored capsules (please check the flavors you want)
I do not have a preference.
The cost of a print is an additional $10. (I understand the quality of the print cannot be determined ahead of time. Each placenta is unique and prints vary. No paint or food coloring will be used to maintain the purity of encapsulation. Prints are on high quality, acid free paper. Umbilical cord keepsakes are already included with the price of encapsulation.)
YES PLEASE! I DO want a print for $10.00.
NO, I do NOT want a print.
A tincture can be prepared using dried placenta. A tincture can last many years and can be taken when hormonal shifts are felt. For example, when breastfeeding is discontinued, during your monthly cycle and even during menopause. Would you like to add a tincture to your order for an additional $35?
Yes! I want a tincture for $35.
No, I do NOT want a tincture.
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