PLACENTA ENCAPSULATION AGREEMENT FORM

PLACENTA ENCAPSULATION AGREEMENT FORM

The Nurtured Leaf, LLC // Alecia Smith, Independant Professional Placenta Specialist Since 2013

CURRENT AVAILABILITY REFLECTED BELOW. This will be updated as clients sign up:
December Due Date: FULL
January 2020 Due Date: FULL
February 2020 Due Date: 1 open
March 2020 Due Date: 3 open
April 2020 Due Date: 3 open
May 2020 Due Date: 4 open
June 2020 Due Date: 4 open
July 2020 Due Date: 5 open
August 2020 Due Date: 2 open

*Please note, if my schedule is currently full for your due date but you are a returning client, please reach out to me!

***Alecia is based out of the rural Enumclaw area and serves any area that is within 40 miles from zip code 98022. Coverage outside of the standard 40 mile radius will include a small travel fee based on distance, beginning at $25. Please contact her at info@thenurturedleaf.com for specific details based on your location if you have questions, prior to signing up.

By completing this form you are hiring The Nurtured Leaf, LLC for Placenta Encapsulation Services.

1Client Details > 2Entire Agreement > 3Payment
Client Name * First Last
Phone * - ### - ### ####
Email *
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
*** Please make sure your address is typed in correctly. For clients who sign up within 3 weeks of their estimated due date, I will mail out a placenta transportation kit to their home address. Also, please notify me if this address will change between now and your due date. Thank you!
Gate Code or Special Instructions
Due Date or Baby's Birth Date * / MM / DD YYYY
Name of partner or person(s) who may contact me about your placenta: First Last
Partner / Contact Person's Phone - ### - ### ####
Planned Place of Birth *
Will this be your first birth? *
Yes No
Have you encapsulated in the past? *
Yes No
Any health concerns during this pregnancy? Are you currently taking any prescription medications? *
Do you know your current GBS (group B strep) status *
Yes, my GBS test was negative Yes, my GBS test was positive I have not yet been tested I declined GBS testing
Have you ever been diagnosed with any of the following blood borne diseases? *
None Herpes Simplex Virus (HSV-1 or -2) Hepatitis B or C (*Most local hospitals won't release the placenta, please consult with your care provider.) HIV/AIDS (*Most local hospitals won't release the placenta, please consult with your care provider.) Other (please list below)
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.

Essential Package // $325
+ Placenta Capsules

Healing Package // $350
+ Placenta Capsules
+ 4 oz Placenta Tincuture

Nurturing Package // $385
+ Placenta Capsules
+ 4 oz Placenta Tincture
+ 80 Organic Lactation Herbal Support Capsules
+ 3 oz Organic Postpartum Herbal Bath
Choice of Placenta Encapsulation Package *
Essential Package // $325 Healing Package // $350 Nurturing Package // $385
Encapsulation Methods

Simply Dehydrated Preparation Method //
Raw Foods Inspired Method of Preparation. Also called "High-Yield" or "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 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.
Choice of Encapsulation Method *
Simply Dehydrated Method Steamed & Dehydrated Method
Would you like any herbs to be added during the steaming process? *(For Steamed & Dehydrated Method only)
Organic Lemon Organic Ginger Organic Cayenne Pepper
Choice of Capsules *
Clear Vegetarian Berry Flavored Gelatin
Additional Options to add on:
(***Please note: These are in addition to what is included in your chosen package)
Complimentary Cord Keepsake Placenta Tincture (4 oz) $35 Organic Healing Salve (4 oz) $35 Organic Healing Salve (2 oz) $20 Organic Elderberry Syrup (16 oz) $28 Organic Elderberry Syrup (8 oz) $15 Organic Elderberry Syrup (4 oz) $8 Organic Postpartum Herbal Bath (3 oz) $15 Organic Herbal Lactation Support Capsules (42 capsules sample pack) $13 Organic Herbal Lactation Support Capsules (80 capsules) $27 Organic Herbal Lactation Support Capsules (160 capsules) $46 Organic Herbal Lactation Support Capsules (320 capsules) $80
Any special requests, or notes?
$0

Total
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