Placenta Works Book Now! Encapsulation Service Intake Form Mother's Name * Phone * (###) ### #### Email * Mailing Address * Baby's Birth or Due Date * MM DD YYYY Planned Birth Place Name of your Midwife or OB/GYN Will this be your first birth? YES NO Are you allergic to latex? YES NO Do you have any food or environmental allergies? YES NO Do you have any infectious diseases, such as HIV/AIDS, Hepatitis, Herpes, Lyme? YES NO Do you have any health complications related to your pregnancy or affecting it? Are you taking any medication? YES NO Which service package would you like to book with our certified specialist today? $250 Capsules, Smoothie, and Cord Keepsake $275 - Includes all of the above, plus your choice of one additional service: Prints or Tincture $300 - Complete package: All remedies (Capsules, Smoothie, Cord Keepsake, Prints, Tincture) plus a bonus Placenta Salve Which additional services are you interested in? Energy balancing for pregnancy, birth, postpartum Maternity, birth, or newborn photography Hypnobirthing and/or transpersonal hypnotherapy How did you hear about us? Do you give permission for photos of your placenta to be used as described above? Yes. You may use the photos. No, do not use my photos. Liability Agreement * I have asked one of the assigned placenta encapsulation specialists at Placenta WorksTM to prepare my placenta in capsule, smoothie, and cord keepsake form. Additionally, if I choose, they will create a keepsake print, tincture and salve for my personal use. I agree to pay the full amount due prior to pickup of placenta. I understand that the retainer of $50 is non- refundable. I agree and confirm I am paying for the placenta preparation services only. My placenta does not contain any transmittable diseases such as hepatitis B, hepatitis C, HIV, AIDS. My care provider and I have determined my placenta is healthy and suitable for encapsulation. Since birth, my placenta has been handled in a way that is suitable for safe food preparation. I understand the following: Placenta WorksTM views each placenta as a sacred connection between mother and child and will treat it accordingly. I will not hold Placenta WorksTM responsible if my placenta is accidently damaged during the encapsulation process or tincture preparation. Placenta WorksTM does not make the determination that my placenta is suitable for consumption. Placenta WorksTM does not make any guarantee of my personal results from consumption of capsules, smoothie, broth, or use of the tincture or salve. Capsules should not be taken during a time of illness, and taking capsules during an illness may worsen the condition. By typing YES below, I release Placenta WorksTM from any and all liability for any effects I may experience after choosing to consume the capsules, smoothie, broth, or use of the tincture or salve prepared for me and my personal use. * Thank you! NOTE:After submitting, you’ll be redirected to PayPal to pay the $50 deposit. A certified specialist from our team will be in touch within 48 hours. Thank you for choosing us! More importantly, thank you for CHOOSING YOU and enriching this experience for you and your NEW BABY. “Abundant birthing blessings to you”— The Placenta Works Team Placenta Works
