placenta encapsulation order form Placenta Booking Form Complete this form to book your placenta encapsulation services. Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Preferred Contact Phone*Email* Estimated Due Date* Where do you plan on giving birth?*St. Joseph's HospitalBellingham Birth CenterBirthroot Birth CenterHome in Whatcom CountySkagit Valley HospitalMt. Vernon Birth CenterHome in Skagit CountyIsland HospitalHome in Island CountyEncapsulation Method*In-Home Plain Steamed PreparationIn-Home Steamed Preparation w/ Lemon & GingerThis is the method you choose to have your placenta prepared.Additional Options* Tincture Prints None, Thank you Pricing is in addition to encapsulation service. Contact us for pricing on these services if you do not wish to encapsulate any of your placenta. Would you like your keepsake cord?*Spiral ShapeHeart ShapeNo, Thank youBecause cords dry differently, we cannot guarantee preferred shapes. Capsule Selection*Strawberry flavored gelatinUnflavored gelatinUnflavored veganDo you have any communicable diseases?* None HIV/AIDS Herpes Gonorrhea Other STIs All information will be kept confidential. Do you have a latex allergy?NoYesPlease read and check each of the following to confirm your placenta preparation contract.* I acknowledge that reported benefits of placenta encapsulation -all though common- are anecdotal, and cannot be guaranteed. It is my responsibility to inform my care provider that I will be keeping my placenta. I will be responsible for bringing my transport kit to my birth place, and ensuring my placenta is sealed in the appropriate containers, and placed under refrigeration within two hours after the birth. If I am unable to arrange for my placenta to be processes before 72 hours after birth, I will properly freeze it until it can be encapsulated. It is my responsibility to call (not email, text or message) Doulas of Bellingham within 12 hours of the birth to arrange for in-home placenta processing. I will arrange for either myself, or another party to be present during processing. I will transport my own placenta to my home, to be processed, using Doulas of Bellingham's protocols. I have informed Doulas of Bellingham of any communicable disease or blood-borne illness I have. I agree to notify Doulas of Bellingham if there was an infection present in mother or baby during labor. I recognize that recommended consumption guidelines are provided for reference, and that I am able, and will, evaluate changes in usage by taking into account my body's responses to the capsules. I agree to the following: Doulas of Bellingham and affiliated Doulas are not licensed medical professionals and do not diagnose, treat or prescribe for any health condition. Services and fees are for the preparation of your placenta, not for the sale of placentas or placenta products. None of these services are approved to diagnose, cure, treat or prevent any disease. The statements made on this website have not been evaluated by the Food and Drug Administration. Use of placenta encapsulation or other services assumes prior discussion with your health care provider; clients are responsible for researching and using these services appropriately. You agree to defend and hold harmless Doulas of Bellingham and all their affiliated Doulas from any liability or damages caused by or from the use of prepared placenta products. The use of placenta products are at your own risk. To secure your due date on the calendar we require a $100 deposit with the balance payable upon arrival to prepare your placenta. After your deposit has been received you will be contacted by Doulas of Bellingham to coordinate the pickup of your placenta transportation kit with instructions. In the event your placenta cannot be encapsulated due to maternal infection or other communicable condition, your deposit will be refunded. If you change your mind about encapsulation or choose another service provider for your encapsulation, your deposit will not be refunded. If unused, you must return the transport kit to Doulas Of Bellingham. Total $0.00 This is the total amount for your selected options. A deposit of $100.00 is required to reserve your service.