Placenta Encapsulation Intake FormIn order to make our journey a smooth one, please fill out this intake form to the best of your ability. In the event that we are not a fit for each other, I guarantee that I will discard this form. Contact Information Name * First Name Last Name Pronouns * Email * Phone Number * (###) ### #### Partner/Support Person's Name First Name Last Name Partner/Support Person's Phone Number (###) ### #### Birthing Information Estimated Due Date MM DD YYYY Obstetrician/Midwife Name Birthing Location (Hospital, Home, Birthing Center, etc) Birthing Location Address Address 1 Address 2 City State/Province Zip/Postal Code Country Health Information Do you have any known allergies? Have you had or do you suffer from any of the following: Group B Strep, Herpes, Lupus, PUPPP, Rubella/Congenital Rubella? Have you experienced any infections or complications during pregnancy? Do you have a history of any blood-borne diseases (e.g., HIV, Hepatitis B/C)? Have you smoked regularly through your pregnancy? If so, please state how many per day & when you stopped if you have stopped. Are you currently taking any medications or supplements? Have you had a cesarean section or are you planning to have one? Birth Preferences and Placenta Handling Do you have a birth plan? Do you want any specific herbs used in the gentle method (e.g., ginger, lemon, rosemary)? Will someone be available to ensure the placenta is properly stored (e.g., in a cooler) until it can be collected? Select Your Service Raw Method Gentle Method Service Add Ons Placenta Tincture 4oz Placenta Salve 4oz Logistics & Timing When do you expect to need the placenta encapsulation services? What is the best way to contact you during the postpartum period? Phone Text Email Do you have any preferences for how the placenta should be collected and returned to you? Additional Questions and Concerns Is there any additional information you think we should know to provide you with the best service? Do you have any questions about the encapsulation process, safety protocols, or benefits? Thank you!
