Mother's Full Name *

First Name

Last Name

Mother's Phone *

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Estimated Due Date *

MM

DD

YYYY

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birth Partner's Name *

First Name

Last Name

Birth Partner's Phone *

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Check Any That Apply

Allergic to latex

Food/Environmental allergy

Any STDs while pregnant

Services & Fees *

Placenta Encapsulation Methods and Add ons

Raw Start (not steamed)

Traditional (steamed)

Cord Keepsake (free)

Placenta Print (free)

Tincture ($35)

Salve ($25)

Flavored Capsules ($10: Mint or Strawberry)

Do you want pictures of your placenta

I can use pictures of your placenta

Basic Package

★ Email or telephone consultation to discuss benefits, preparation process & logistics, and assistance in determining if and how Placenta Services can benefit you, as well as on-call availability after hire to address questions or concerns as they arise. ★ Pick up of placenta & drop off of capsules ★ Your choice of placenta encapsulation method ★ One naturally made placenta print, on charcoal paper & cord keepsake (in the shape of a heart or spiral, size permitting) ★ Handout detailing intake recommendations of your placenta products, as well as benefits of consumption.

Basic Package ($275)

Full Package

★ Same as above ★ Placenta Tincture ★ Herbal Salve ★ Mama Herbal Bath

Full Package ($350)

Deposit

A $50.00 deposit will ensure that I have availability and that I will be in town one week before & one week after your EDD. Balance is due within 24 hours of birth. Additional services are available for an extra fee. Deposits can be made electronically via paypal, venmo, zelle, check, or cash. Paypal must be paid via “Friends & Family”. Payment in full is due before or at time of delivery of the capsules. You may cancel this contract at any time prior to services being rendered. If you cancel after I have picked up your placenta (or arrived for in-home preparation) but before preparation begins, I will return your placenta to you upon request and no further payment is required. If you cancel after the encapsulation process has begun: the balance is due in full and no refund will be given. Payment plans can be arranged in advance, when necessary.

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Guidelines for YOU

H.B. 1670 is a law passed in Texas giving the mother the right to take your placenta home, so please let me know if there is any issue between your care provider and your desire to have your placenta. Talk to your care provider during a prenatal visit about your intended birth place’s policies in regards to releasing the placenta. Sign any forms required and have them placed in your file. If you are birthing in a hospital: remind your labor nurse upon arrival, and on change on shift if applicable, that you plan to take your placenta. Following the birth, your placenta must be placed in a sealed container or double ziplock gallon-sized bags and labelled with your name. You are responsible for ensuring that you have met all the requirements of your birthing facility and completed the appropriate paperwork for release, if any. You are responsible for the safe handling and appropriate storage of your placenta prior to pickup by the specialist. Time frame - If you give birth between the hours of 10PM and 5AM - please put your placenta in the cooler with ice at the bottom, double bagged (or container) placenta then ice on top. I will come get it in the morning. Call me at 281-639-4251 after the birth to arrange a time to pick up the placenta (DO NOT TEXT MESSAGE ME). If you are not able to contact me within 3 days of the birth and the placenta has been appropriately refrigerated since the birth, please freeze the placenta until you are ready for pickup. Encapsulation and capsule delivery generally takes 1-2 days for a refrigerated placenta. A frozen placenta will take an additional 1-2 days so that it can be safely thawed.

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