Placenta Encapsulation Agreement

Client Information
Todays Date*

MonthDayYear
Mother's Name *

First NameLast Name
Partner's Name *

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Estimated Due Date *

MonthDayYear
I am expecting: *

SingletonTwinsTriplets/Other
Care Provider *

First NameLast Name
Birthplace*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Any pregnancy complications*
Are you taking any medications?*
Are you allergic to latex?*
Do you have any infectious diseases, such as HIV/AIDS, Hepatitis, Herpes, Lyme? **
Why have you chosen to encapsulate your placenta?*
Order Form
A free print of your placenta is included in your package. This is optional. Would you like a placenta print? *

Yes (with blood)Yes (with food safe icing color)No Thank You
A free cord keepsake is included in your package. This is optional. Would you like a cord keepsake?*

Yes - heartYes - spiralYes - infinity loopYes - spell out LoveNo Thank youOther
I would like the following Add On Services: *

Placenta Tincture (4 oz)Placenta Smoothie CubesNone
Photo Release
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 as described?*

Yes, you may use the photosNo, you may not use the photos
Client Responsibilities
- 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. Some hospitals release to me right away, and am able to come pick up with an iced cooler. Others will only release the placenta at discharge, and only to the mother. If this is the case for you, you will need to bring a cooler for transport. I will pick up from your home and take your cooler(as to assure less handling and transfer) and will return your cooler with your completed capsules.
- 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. See that it has been properly stored and labeled with your name before it leaves your room for refrigeration.
- If you are delivering at home, put your placenta into a covered container, secured biohazard bag or double ziplock bag. The container must be labeled with your name before I pick it up.
- It can remain at room temperature for up to 2 hours following the birth. Refrigerate or put it on ice as soon as reasonably possible. Improperly handled placentas are susceptible to spoilage.
- I cannot encapsulate placentas that are examined in a hospital's pathology lab.
- Call or text message me at [ 904-575-8314] after the birth to arrange a time to pick up the placenta. Please call between 7am and 10pm.
- If you are not able to contact me within 3 days of the birth, freeze the placenta until you are ready for pickup.
- Encapsulation and delivery takes 2-3 days for a refrigerated placenta. A frozen placenta will take an additional 1-2 days so that it can be safely thawed.
Payments, Refunds, and Cancellations
- A retainer/scheduling fee of $50.00 is due upon booking services. This fee reserves your EDD in my calendar and ensures I am on call and available to pick up your placenta.
- Payment in full is due upon pick-up of your placenta.
- 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 my calendar. (an invoice that can be paid online will be sent to your email via paypal within 24 hours of receipt of this agreement).
- 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.
Turnaround Guarantee
I do my best to have your placenta back to you as quickly as it can safely be prepared. This is usually within 2 days from the time 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 fourth 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 3 days.

- 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. Some hospitals release to me right away, and I am able to come pick up with an iced cooler. Others will only release the placenta at discharge, and only to the mother. If this is the case for you, you will need to bring a cooler for transport. I will pick up from your home and take your cooler(as to assure less handling and transfer) and will return your cooler with your completed capsules.
- 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. See that it has been properly stored and labeled with your name before it leaves your room for refrigeration.
- If you are delivering at home, put your placenta into a covered container, secured biohazard bag or double ziplock bag. The container must be labeled with your name before I pick it up.
- It can remain at room temperature for up to 2 hours following the birth. Refrigerate or put it on ice as soon as reasonably possible. Improperly handled placentas are susceptible to spoilage.
- I cannot encapsulate placentas that are examined in a hospital's pathology lab.
- Call or text message me at [ 904-575-8314] after the birth to arrange a time to pick up the placenta. Please call between 7am and 10pm.
- If you are not able to contact me within 3 days of the birth, freeze the placenta until you are ready for pickup.
- Encapsulation and delivery takes 2-3 days for a refrigerated placenta. A frozen placenta will take an additional 1-2 days so that it can be safely thawed.
Waiver of Liability

·I understand and acknowledge that 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. I acknowledge that [ Kira Warren ] has provided me with concrete information about both the benefits and risks of placenta encapsulation, and have read all information on the Jacksonville Placenta website. I understand that my placenta will be processed in Kira Warren's home Kitchen, and handled and encapsulated according to OSHA bloodborne pathogens universal precautions and [Florida/USA] 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 [ Kira Warren ], I waive any and all rights to hold her, or my capsules responsible for any undesired effect of consuming the capsules. I put full trust and acknowledgement that my placenta is being handled in a sanitary and safe environment. I have disclosed to [ Kira Warren ] my STD status. I understand that upon receiving my capsules, [ Kira Warren ] is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules. I do not hold [ Kira Warren ] responsible or liable for any transport mishap that is beyond her control (ex. car accident or detainment).
By signing, I agree to the above terms and conditions*
Should be Empty:

Client Information

Order Form

Photo Release

Client Responsibilities

Payments, Refunds, and Cancellations

Turnaround Guarantee

Waiver of Liability