Sacred Space Birth Services, Placenta Preparation Intake
Thank you for choosing Sacred Space Birth Services as your placenta preparation provider. Please fill in the requested information below. All information that you provide here will be held in confidence.
First and last name *
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Address *
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Email address
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Estimated due date *
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Mobile phone *
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Planned place of birth *
If in a hospital, please specify which one
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OB or Midwife Name *
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Home Phone
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Your D.O.B. *
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Is it okay to contact your partner regarding your placenta encapsulation? *
Partners name
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Partners phone number
Only if you choose to have your partner speak on your behalf for your placenta preparation
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Do you have any food allergies or sensitivities? *
If so. please list which ones?
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Do you have any food sensitivities or allergies to Lemon, Ginger or Hot Pepper? *
Are you allergic to latex? *
Have you had any of the following during this pregnancy: *
Please check all that apply
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Have you had any other infections or diseases besides the ones listed above? *
If so please comment int he next question space
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Is there anything you would like to tell me about this pregnancy, birth or placenta? *
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Doulas Name
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Doulas contact number
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Placenta Preparation Information and Policies
DISCLAIMER *
Placenta preparation, as offered by Sacred Space Birth Services, is not clinical, pharmaceutical, or intended to diagnose or treat any condition. Placenta preparation is not meant to be a replacement for medical advice, medical care or medicine. Services and fees are for the preparation and encapsulation of your placenta and not for the sale of the pills. Families that choose to utilize the placenta preparation services take full responsibility of their own health and for researching and using placenta remedies. Sacred Space Birth Services does not make any guarantee as to the efficacy, but does guarantee the highest quality of service. Benefits of placentophagy are supported by ongoing research but have not been evaluated by the FDA. (Please initial below )
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STORAGE *
Whether birthing at home or in a hospital, please ensure that your placenta is kept fresh. It can remain at room temperature for 3-4 hours following the birth. After that it should be refrigerated or otherwise kept cool. If you are practicing some form of delayed cord cutting beyond the 3-4 hour window or lotus birth, please contact me. If it is going to be more than 72 hours before the placenta can be prepared, it should be frozen. (A frozen placenta will take somewhat longer to prepare since I prefer to gently defrost it prior to preparation.) You can prepare your placenta for transport by placing it in 2 large ( gallon size), freezer strength zip-lock bags, then into a cooler or large covered bowl or bucket with ice/ice packs or into a refrigerator. ~~~ It is important to note that there may be circumstances under which your placenta can not be used. Significant abnormalities of the placenta may necessitate your doctor or midwife sending your placenta to Pathology for further examination. Other conditions, such as signs of infection in the mother during labor, may mean that consuming your placenta will not be beneficial to you. If in doubt I will consult with you before proceeding. It should be possible to claim your placenta after Cesarean surgery. ( Please initial)
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CLIENT RESPONSIBILITY *
It is your responsibility to notify me after the birth (ideally within 24 hours) to make arrangements for pick up, drop off, or for me to come to your home. Failure to do so may result in delayed placenta preparation and encapsulation and may cause spoilage of the placenta which would render it unusable for encapsulation. ~~~ It is your responsibility to discuss release of your placenta from the hospital where you give birth and to ensure proper labeling and storage of your placenta in a refrigerator or cooler with the placenta placed on ice until it can be picked up or delivered for preparation and encapsulation. Your placenta should not be treated with alcohol, formalin, or any other preservative. Please contact me if you need assistance with hospital release. You should contact the hospital directly, not just your doctor or midwife. (Please initial.)
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SERVICE AGREEMENT
Fees *
Fees for the encapsulation preparation are $300 for non-doula clients, $250 for doula clients, to be paid at the time of service. Placenta prints only (without encapsulation preparation) are $50. A travel fee of $50 for services in excess of 25 miles from Huntington, NY. may apply. Cash/Check/Credit/Debit accepted. Please make checks payable to Mary Betsellie Credit/Debit Card payments accepted via PayPal online at the time of service. Alternative payment plans available upon request. There is a fee of $35 for returned checks. All fees are non refundable.
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Preparation Preferences *
Check the services that you want as well as the location.
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Do you require veggie caps? ( for vegetarians and vegans) * *
Agreement *
I have read, understood, and agreed to the above procedures, information, and statements of policy. By typing my name below, as an electronic signature, I give my consent to release my healthy placenta to Sacred Space Birth Services for the purposes of encapsulation. I accept the responsibility of gaining possession of the placenta after the birth, handling of the placenta appropriately prior to Sacred Space Birth Services taking possession of it, and notifying Sacred Space Birth Services of my birth within 24 hours. If selecting Off-Premises services, I authorize the release of my placenta to Sacred Space Birth Services and I authorize Sacred Space Birth Services to transport my placenta for preparation. * Please type your name, as your electronic signature, to show that you have read all of the above information and that all of the above information submitted by your is true and accurate.
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FOR OFFICE USE ONLY
Date of Birth
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Date completed
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Photo location
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Additional info
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