Client Intake and Placenta Encapsulation Form

Client Intake and Placenta Encapsulation Form

Please fill out the following information to help us serve you better.
Estimated Due Date*

MonthDayYear
Date
Full Name*

First NameLast Name
Email
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Delivering Hospital*
How did you hear about us?
Any complications or concerns during pregnancy?
Placenta encapsulation is the act of taking a fresh, raw placenta, washing the placenta steaming or slicing the placenta raw, dehydrating, grinding, and putting the placenta powder into consumable capsules. All processes are done with respect and education of that placenta and in a sanitary environment. I adhere to strict OSHA guidelines and follow proper food safety standards. The placenta capsules that are being prepared are for your consumption only and are not designed to reverse medical conditions or ailments from pregnancy, treat postpartum depression, ensure normal milk supply, or replace medical attention.
You understand that I am not a licensed medical professional such as a care provider or physician and I am not able to diagnose, treat, or prescribe for any health condition. Services and fees are for encapsulating your placenta, not for the sale of these capsules. Each woman will react to her placenta capsules in different ways. Some of the ascribed benefits of placenta consumption are supported by ongoing research; however, these benefits have not been evaluated or approved by the United States government or the Food and Drug Administration. It is your responsibility to determine whether using placenta capsules can be beneficial to your well-being postpartum*

YESNO therefore, you agree that you NO LONGER WANT YOUR PLACENTA ENCAPSULATED
Are you a BBC client?

YesNo
Any allergies to medication or herbs?
Any current medications?
It is also your responsibility to inform me of any known blood-borne illness (es) (such as HIV, hepatitis, etc.) that could place me or any others who may come into contact with your bodily fluids (specifically maternal and fetal blood as well as amniotic fluid) at risk. PLEASE LIST ANY KNOWN
Group Strep B Screening

PositiveNegative
Diagnosed or experienced any symptoms of a STD or infection

PositiveNegative
YOU UNDERSTAND ITS YOUR RESPONSIBILITY to notify me within 2 hours of the birth so that we can work together to make arrangements for pickup or drop off. Failure to do so may result in delayed placenta preparation and encapsulation and may cause decreased potency of nutrients, hormones, and other beneficial attributes of the placenta. Improper placenta storage before pick up or drop off may result in spoilage. It is your responsibility to discuss the release of your placenta from the facility where you will give birth during the prenatal period and to ensure proper storage of your placenta in a refrigerator or cooler. This can be done by placing the placenta on ice until it can be retrieved for preparation and encapsulation. THATS MY DOULA WILL PROVIDE A COOLER FOR PICKUP.

YES
Desired method of encapsulation $350*

Chinese Tradional Method :This method involves steaming the placenta gently with possible herbs such as; lemon, ginger, oregano, and capsaicin pepper (additional herbs may be used). Adding these in the steaming process is thought to bringout the placenta’s natural healing properties. It is dehydrated at 125 degrees. Capsules are made from vegetarian capsules.Raw Prepped and Sterilized MethodThis method involves thoroughly cleaning and sterilizing the raw placenta before preparing it for immediate use. The fresh, sterilized placenta can then be added to food items such as smoothies, soups, or baked goods (like cookies) for consumption. This method is ideal for those who want to benefit from the placenta’s nutrients in its most natural state. It must be used within 48 hours of preparation to ensure freshness and safety. Proper refrigeration is required.Simple Steam MethodThis method is similar to the other preparation styles, but with one key difference: it eliminates the dehydration process. The placenta is thoroughly cleaned, gently steamed, and infused with herbs such as lemon, ginger, or other selected options. It is then prepared for immediate use in food items like soups or smoothies. This method allows for maximum freshness and is ideal for those who want to consume their placenta in a more natural, edible form. Must be used within 48 hours and properly refrigerated for safety.High Yield MethodThis method skips the steaming process and involves slicing the raw placenta before placing it directly into the dehydrator. It is chosen by those who follow a raw food diet or prefer to avoid heat processing, as it helps preserve more of the placenta’s natural enzymes and nutrients. The placenta is never heated above 115°F, making it compatible with raw food principles. This method must be started within 48 hours after birth to ensure freshness and safety. Dehydration typically takes 12–24 hours, and the finished product is encapsulated using vegetarian capsules.Simple Dehydration MethodThis method also skips the steaming process. The placenta is sliced while still in its raw state and then dehydrated at 160°F, following USDA safety guidelines for dehydrating meat. At this temperature, harmful bacteria and enzymes are destroyed, reducing the risk of contamination. It’s believed that essential hormones are still retained and that iron becomes more bioavailable, supporting the placenta’s healing properties. The final product is encapsulated using vegetarian capsules.I AM NOT INTERESTED IN PLACENTA ENCAPSULATION
Would you like to add on?

Placenta Tincture ($50)Placenta Healing Salve ($35)Placenta Print (Basic) ($35)Customized Placenta Print ($125)Customized Baby Picture Book ($75)Placenta Affirmation Plant ($75)Womb warming oil ($35)Postpartum Herbal Remedy Package. (6 week supply) ($50)Vaginal Steaming Herbs (at home use) ($25)Closing Of The Bones Ceremony ($125)Reiki on placenta ($50)Distance REIKI mom ($85)Assistant Stetch Therapy (30 minutes) ($50)
I have read, understood, and agreed to the above information. I accept the responsibility of gaining possession of my placenta, and notifying my placenta specialist within 2 hours of my birth. I understand the importance of appropriate handling and storage of the placenta. By signing below, I authorize the release of my healthy placenta to Davvie Moore, That's My Doula LLC for Placenta Encapsulation and herbal preparation for my personal use.
Signature
Address for product delivery

Street Address

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CityState / Province

Postal / Zip Code
Responsibilities of the Placenta Specialist: Maintain full client confidentiality at all times. Provide a sterilized cooler for placenta pickup and return it within 72 hours of receiving the placenta.Inspect, sanitize, and process the placenta following professional standards (e.g., hospital-grade sanitation, OSHA/APPA/food handler protocols) Use separate tools and prep space, processing one placenta at a time to prevent cross-contamination. Ensure highest standards of cleanliness, safety, and quality throughout encapsulation.

THATS MY DOULA, ACKNOWLEDGES THIS STATEMENT
I understand that’s My Capsule Yield EstimateIs approximately 75–120 capsules will be provided, depending on the size of your placenta (typical range is 100-120).

YES

Payment Amount*

USDDescription

Payment Methods

Credit Card

Apple Pay

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Cash App Pay

ACH Bank Transfer

I understand that a mileage fee ($125) and shipping fee ($25) is included in my price*

YesNo
I understand that I must pay my deposit and an invoice with the balance will be sent to me via text or email*

YESNO , we can’t move forward with encapsulation process
Placenta Encapsulation Agreement Summary I understand that my placenta may not be usable if sent to pathology or if health concerns arise (e.g., infection). Davvie Moore, That’s My Doula, will always check in with me before determining if my placenta is safe for encapsulation. A $200 non-refundable deposit is due when returning this contract. Refunds are only offered if my placenta is sent to pathology or deemed unsafe—minus a $50 consultation fee. No refunds are given within 7 days of my estimated due date or after processing has started. The total is $350, or $425 if the form is signed at the time of pickup. I appreciate the clarity and care in this process.*

Yes, I understand
Signature
THANK YOU AND CONGRATULATIONS IN ADVANCE ON A HEALTHY AND HAPPY BIRTHING EXPERIENCE!

THATS MY DOULA

DAVVIE MOORE

216-440-2473
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