Client Name *
First
Last
Phone *
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Email *
Address *
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Canada
Australia
Netherlands
France
Germany
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Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
Gabon
Gambia
Georgia
Ghana
Greece
Grenada
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
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 *
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Name of partner or person(s) who may contact me about your placenta:
First
Last
Partner / Contact Person's Phone
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Planned Place of Birth *
Cascade Birth Center
Center For Birth
Eastside Birth Center
Evergreen Hospital
Good Samaritan Hospital
Home Birth
Lakeside Birth Center
Madigan Army Medical Center
Moonrise Birth Center
Multicare Auburn Medical Center
Multicare Covington Medical Center
Other
Overlake Hospital
Providence Everett Hospital
Puget Sound Birth Center Kirkland
Puget Sound Birth Center Renton
Sprout Birth Center
St. Anne Hospital
St. Elizabeth Hospital
St. Francis Hospital
St. Joseph Medical Center
St. Joseph Midwifery Birth Center
Swedish Ballard Hospital
Swedish Edmonds Hospital
Swedish First Hill Hospital
Swedish Issaquah Hospital
Tacoma General Hospital
The Birth Cottage
The Birthing Inn
UW Medical Center - Montlake
UW Medical Center - Northwest
Valley Medical Center
Virginia Mason
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 // $350
+ Placenta Capsules
Healing Package // $375
+ Placenta Capsules
+ 4 oz Placenta Tincuture
Nurturing Package // $400
+ 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 // $350
Healing Package // $375
Nurturing Package // $400
Encapsulation Methods
Simply Dehydrated Preparation Method //
Raw Foods Inspired Method of Preparation. Also called "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 slightly 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 (NOT CURRENTLY AVAILABLE - Manufacturer supply issue.)
Additional Options to add on:
(***Please note: These are in addition to what is included in your chosen package)
Complimentary Cord Keepsake
Additional Placenta Tincture (4 oz) $35
Organic Elderberry Syrup (16 oz) $30
Organic Elderberry Syrup DIY Kit - Original $15
Organic Elderberry Syrup DIY Kit - Super Immune Boost $17
Organic Postpartum Herbal Bath (3 oz) $15
Organic Herbal Lactation Support Capsules (42 capsules sample pack) $15
Organic Herbal Lactation Support Capsules (80 capsules) $25
Organic Herbal Lactation Support Capsules (160 capsules) $45
Organic Herbal Lactation Support Capsules (320 capsules) $80
Twin Placenta (with 2 placenta's) SEPARATE processing $50. *Each placenta will be processed and bottled separately, rather than combined.
Choice of Delivery Shipping Method
(Upon completion of your package, you will receive a text from me notifying you it is ready for shipping.) Please choose your delivery preference. *
USPS Priority 1 Day
USPS Priority 1 Day WITH signature request
Any special requests, or notes?
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