Birth location and address:
Scheduled birth day (if applicable)
Where did you hear about us?
Medications taken during the pregnancy?
Are you a smoker?
Please list any known allergies.
When using food-grade dyes, what color(s) would you like your placenta prints?
I agree to the following:
To the best of my knowledge, my placenta does not contain any transmittable diseases such as Hepatitis B, Hepatitis C, HIV or AIDS.
To the best of my knowledge, I have not had a uterine infection during the current pregnancy
My care provider and I have determined that my placenta is healthy and suitable for consumption.
I will arrange for someone to contact Palouse Placenta following the birth of my baby so that they may come and pick up my placenta.
I will inform my care provider that Palouse Placenta will be picking up my placenta, in addition to signing any release forms prior to her arrival.
I will allow Palouse Placenta to take my placenta from the place that I am birthing my baby for the sole purpose of herbally preparing it.
I will let Palouse Placenta know if any complications arose during labor, such as fever, infection, meconium, etc.
I will bring a cooler to keep the placenta in, on ice, in my room. I agree to keep my placenta in my sight at all times to ensure it does not go to a lab where it may be contaminated by chemicals or other harmful substances rendering it unsafe for consumption. If the hospital must test the placenta, a small piece can be taken off the maternal side and sent to the lab, while the intact placenta is stored properly. I am responsible for providing cooler. I understand that the same post birth care instructions apply to cesarean births.
I will follow the self-dosing instructions and notify Palouse Placenta of any problems
Palouse Placenta encapsulation specialists are not pharmacists, pharmaceutical representatives, holistic practitioners, herbalists, or medical doctors. Benefits of placenta encapsulation are supported by ongoing research but have not been evaluated by the Food and Drug Administration. Placenta Encapsulation as it pertains to this contract agreement is for natural nutritional supplementation and is intended solely for ingestion by the mother who has birthed the placenta(s) and not for her family members, friends, or other individuals. This is a natural nutritional supplement, and as such, cannot be guaranteed to produce specific results. The services offered by Palouse Placenta are not clinical, pharmaceutical, or intended to diagnose or treat any condition. Families who choose to utilize the services take full responsibility of their own health and for researching and using the remedies. Palouse Placenta makes no guarantee as to capsule efficacy, but does guarantee the highest quality of service and preparation. Always speak to your care provider regarding any questions about your health, safety and well-being. Placenta services are not meant to be a replacement for medical advice, medical care or medicine. Mothers experiencing symptoms of postpartum depression, low milk supply, or any other clinical concerns; need to speak with their medical care provider to diagnose and treat any existing symptoms or potential conditions. While many women have found placenta encapsulation to be a wonderful and amazing gift, you are still encouraged to seek appropriate assistance and medical care when necessary. It is always okay to ask for help.
Thank you for filling out our contact! We will be in touch with you within 24 hours to provide you with your instructions, go over the process, discuss payment options, and schedule a complimentary consultation (if you would like one).