Placenta Encapsulation Contract
Complete this form to hire Sacred Lane Placenta to encapsulate your placenta. At the end of the form you can pay the $50 deposit online. This will be applied to the $250 encapsulation fee.
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Baby's Birth or Due Date
Date Picker Icon
Planned Birth Place
Name of your Midwife or OB/GYN
Will this be your first birth?
Are you allergic to latex?
Do you have any food or environmental allergies?
If previous question is yes, please explain.
Do you have any health complications? Are you taking any medication?
Raw: sliced raw and dehydrated at 160 degrees. Steamed(TCM): steamed, sliced and dehydrated at 160 degrees. For more information on methods see here: http://www.sacredlaneplacenta.com/services.html
I choose this type of capsule
Size 0 Regular Gelatin
Size 0 Clear Vegan
I choose this method of preparation for my placenta:
Just a few extra choices about your service package.
Flavored Gelatin Capsules (additional $10)
Specialty Flavor Request
A free print of your placenta is included in your package. This is optional. Would you like a placenta print?
We take a photo of your placenta for our records. Would you like a copy of it emailed to you? *
A free cord keepsake is included in your package. This is optional. Would you like a cord keepsake? Shape idea: heart, circle, spiral, infinity loop
Are you interested in any of the following add ons? Price is $25 for one, $40 for two, $50 for three.
High quality canvas print
Half & half preparation (encapsulation in half one method and in half another)
Special Instructions. Comments. Questions.
I take photos of your placenta for record keeping purposes. These photos are available to you at any time. With your permission I may use these photos for marketing, advertising, education, peer review or promotional purposes in print or online. Identifying information will not be shared under any circumstances.
Do you give permission for photos of your placenta to be used as described above?
Yes. You may use my photos
No. Do not use my photos
Payment, Cancellation & Refund Policy
- Payment in full is due before delivery of the capsules. - You may cancel this contract at any time but the $50 retainer is non-refundable and covers time spent prenatally and holding aside your space on our calendar. - 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 even if you choose not to take delivery of the finished capsules.
- 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 care providers upon arrival that you plan to take your placenta and remind them again during pushing. - Put your placenta into a covered container, secured biohazard bag or double ziplock bag. The container must be labeled with your name before we pick it up. - It can remain at room temperature for up to 4 hours following the birth. Refrigerate or put it on ice as soon as reasonably possible. Improperly handled placentas are susceptible to spoilage. - Do not let the placenta out of your sight. I cannot encapsulate placentas that are examined in a hospital's pathology lab. - Call or text message me at (260)460-7686 after the birth to arrange a time to pick up the placenta. Please call as soon after birth as possible. - If you are not able to contact me within 4 days of the birth, freeze the placenta until you are ready for pickup. - Encapsulation and delivery takes 1-2 days for a refrigerated placenta. A frozen placenta may take additional time so that it can be safely thawed.
Two Day Turnaround Guarantee
I do my best to have your placenta back to you as quickly as it can safely be prepared. This is usually the day after I pick it up and sometimes the day following. Clients who sign this contract before labor begins receive a turnaround time guarantee. If I deliver your capsules on the third day after pickup or later you will receive a discount of $25. I may choose to have a backup encapsulator process your placenta if I have received more than one placenta at a time so that I can meet the turnaround deadline. Clients who contact me for encapsulation after labor begins will receive second priority to contracted clients and do not receive a turnaround guarantee, although I will still strive to return your capsules within 2 days.
Limitations and Disclaimer
I understand and acknowledge that in accordance to Indiana law, choosing to encapsulate my placenta is not intended to prevent or treat any physical or mental diseases, ailments or symptoms and that I am choosing to consume my placenta for my own personal beliefs, whether it be spiritual or cultural. I also acknowledge that there are no statewide regulations preventing me from obtaining and encapsulating my placenta in my home. I acknowledge that Kirsten Lane has provided me with concrete information about both the benefits and risks of placenta encapsulation, and have read all included documents. I understand that my placenta will be handled and encapsulated according to OSHA and Indiana Food Safety and Handling standards, and will be cleaned, cooked, dehydrated and put into pill form in a sanitary and disinfected work space. Upon receiving my placenta capsules from Kirsten Lane, I waive any and all rights to hold her responsible for any undesired effect of consuming the capsules. If my placenta is not encapsulated in my own home, I put full trust and acknowledgement that it is being handled in a sanitary and safe environment. I understand that upon receiving the pills, Kirsten Lane are no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules. I do not hold Kirsten Lane responsible or liable for any transport mishap that is beyond her control (ex. car accident or detainment).
I agree to the preceding Client Responsibilities, Limitations and Disclaimer and Refund Policy by signing below:
Contract complete upon submission of a $50 retainer fee. Please choose your preferred method of payment.
Send to email@example.com via PayPal
Send via Venmo
Check or money made payable to Kirsten Lane (1625 S 600 E, Avilla, IN 46710)
Custom Paypal invoice sent to your email
Did you attend an educational event or book during a promotion?
How did you hear about Sacred Lane Placenta?
Name of partner or other person(s) who may contact us about your placenta:
Should be Empty: