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Mama's Name *

First Name Last Name

Partner's Name

First Name Last Name

Mama's Phone Number *

Area Code Phone Number

Is there another number someone may call or text me from?

Area Code Phone Number

E-mail *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Estimated Due Date *

Month Day Year

Planned birth place *

Is this your first birth?

Yes, this is my first birth No, this is not my first birth

Do you have any infectious diseases such as HIV/AIDS, Hepatitis, Herpes, Lyme? *

No Yes

If Yes, please explain

Are you pregnant with multiples? *

Multiple Pregnancy Fee

An additional $25 will be charged to cover the extra supplies and time needed to process multiple placentas

Please Check each box once you have read and agreed to it. A check will represent clients initials. *

Placenta Services Description- Placenta encapsulation is the process of preparing your placenta after the birth of your baby by dehydrating, powdering, and placing it into capsules for you to use as you see fit. Ingesting the placenta (placentophagy) is believed to prevent postpartum depression, increase energy levels, shorten healing time, increase milk production and provide an over-all feeling of wellness to a mother during her immediate postpartum period. Qualifications and Disclosure To ensure a safe and healthy encapsulation experience I have trained with the APPA (Association of Placenta Preparation Arts) and strictly adhere to all OSHA blood-borne pathogen standards and safe food handling regulations set forth by the state of California. I am not a licensed medical professional; therefore, I am unable to diagnose, treat, or prescribe for any health condition. Many of the benefits of placentophagy are supported by evidence based research but have not been evaluated by the FDA. The services offered in this agreement are not clinical, pharmaceutical, or intended to diagnose or treat any condition. Families who choose to utilize these services take full responsibility for their own health and for researching and using placenta remedies. Light in the Womb Birth Services does not make any guarantee as to the efficacy of placenta products, but does guarantee the highest quality of service. Client Responsibility- It is your responsibility to notify me when you are in labor and when you have given birth to make arrangements for pick up (ideally within 2 hours) so the placenta remains fresh. Failure to do so can result in a delay in placenta preparation and encapsulation which may cause spoilage of the placenta rendering it unusable. It is also the clients responsibility to discuss the release of your placenta from the hospital where you give birth (or backup hospital for home births) and to ensure proper labelling and storage of your placenta in a refrigerator or cooler with the placenta placed on ice until it can be picked up for preparation. Your placenta must not be treated with alcohol formalin, or any other preservative. If your placenta has been sent to the pathology lab it will be unusable as sanitation cannot be guaranteed. It is possible to retain your placenta for release if you have a cesarean birth, it is your responsibility to discuss this with your doctor or midwife. Please contact me if you need assistance with hospital release. You should contact the hospital directly, not just your doctor or midwife, before the birth to find out their policy on releasing the placenta. Placenta Service Provider Responsibilities - My responsibilities include maintaining client confidentiality, committing to preparing and returning your products to you within 72 hours of receiving your placenta (usually within 25-48 hours), and upholding the highest standards of cleanliness, safety, and quality of professional placenta preparation services. Although I commit to being on-call to prepare and deliver your products in a timely manner, please remember that I am also a birth doula. In the event that I am called to attend a birth, there may be a 24 hour delay in preparing or delivering your placenta products. Packaging and Transportation - It is important to include your plans for your placenta in your birth plan if you have one and have your partner or doula remind your health care team about your wishes at the time of our baby’s birth. It is very important that your placenta be handled and stored properly before preparation to ensure the safety and effectiveness of your products. Whether birthing at home or in a hospital, please ensure that your placenta is kept fresh. It can remain at room temperature for 3-4 hours following the birth. After that it should be refrigerated or placed in a cooler with ice packs. I prefer if you use a disposable styrofoam cooler. Do not place the placenta directly on ice, place it in a couple of large, freezer strength ziplock bags or in a large sealable container first. If you are practicing some form of lotus birth, ice packs may be wrapped up with the placenta to prevent spoilage. If it is going to be more than 4 or 5 days before the placenta can be prepared, it should be frozen (a frozen placenta will take somewhat longer to prepare since it will need to slowly thaw before preparation.) Preparation Methods - There are two methods of preparation. The Traditional Chinese Medicine (TCM) method involves first draining the placenta of blood, steaming the placenta over ginger, lemon, and hot peppers. These herbs are included in the steaming water only, and are not incorporated into the capsules. Your placenta will then be dehydrated and ground for encapsulation. This method is thought to kill bacteria and reduce the risk of spoilage. The Raw method involves draining the placenta of blood and immediately dehydrating it before being ground for encapsulation. This method is thought to yield more hormones and nutrients. Raw preparation yields more capsules than does TCM preparation and clients report fast-acting results over the short term. TCM preparation reportedly gives a more steady, slow-release result lasting over a longer term. Refund Policy - If you choose to terminate this contract you must do so before you request your placenta to be picked up for a full refund minus the $50 retainer fee. If your placenta is not picked up, or in the event that your placenta cannot be used for medical reasons, a refund will be given to you minus the $50 retainer fee. If you choose to terminate the agreement after your placenta has already been picked up, but before the preparation process has begun, you will be refunded minus the retainer fee plus an additional $25 fee for transport. Your placenta will also be returned to you for proper disposal. If you decide you do not want your finished capsules, or any additional services agreed upon at the time of this contract, after the preparation and encapsulation process has begun, you will not receive a refund of any payments made and will still be responsible for any remaining balance that may be left in the original service agreement.

Preparation Method *

Raw Method Traditional Method

The Traditional Method used to be called the Traditional Chinese Medicine Method because it is steamed over water that includes lemon, ginger and hot peppers. You may decline any or all of these ingredients. Nothing is added to the placenta, only the water, so it will not be included in the capsules. *

Lemon, ginger, and hot pepper are fine Do not steam with Lemon Do not steam with Ginger Do not steam with Hot Pepper

Capsule Type *

Regular Vegetarian Capsules FREE Strawberry Flavored Gelatin Capsules $10

Placenta Tincture. It is my opinion that every mama should order a placenta tincture. With this tincture you can enjoy the benefits of your placenta all the way into your menopause years. It lasts forever!! *

Yes, please add a tincture for $35 No Tincture

Are you interested in a Placenta Print? *

Yes, make me a print for $15 No Print

Photo Release *

I give permission for Light in the Womb to photograph my placenta before, during, and after processing. These photos may be used (anonymously) as marketing, advertising, promotional or educational reasons in print or via the internet. I do not give permission to Light in the Womb to photograph my placenta I would like a digital photo of my placenta emailed to me

Consent to Statistical Data *

I give permission to Light in the Womb to collect statistical data of my placenta services. This may include number of capsules made, chosen method of preparation, dosage utilized by client, noted effects as reported by the client, comments on services rendered and provider feedback. I do not give permission to Light in the Womb to collect statistical data of my placenta services

My Order: *

DEPOSIT ONLY!! Do not check any other box besides this box to make your $50 deposit to reserve your spot on my Calendar. DO NOT check this box if you want to pay in full now. $ 50