Name *

First Name

Last Name

Partner's Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

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Alternate Phone

Women who have just given birth don't usually have their phones nearby after giving birth. Please provide a phone number of someone who will be with you that I can contact to arrange picking up the placenta in case I can't reach you.

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Estimated Due Date *

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What is Placenta Encapsulation and what are the limitations? *

Placenta encapsulation is the process of preparing the mother’s placenta after the birth of her baby(ies) (by separating the membranes and umbilical cord from the placenta and rinsing and draining maternal and fetal blood) and dehydrating it to then be ground and placed into capsules for the mother to ingest as she sees fit. The ingestion of the placenta is known as “placentophagy.” The purpose of placentophagy by the mother is to reintroduce the beneficial vitamins, minerals, hormones, proteins, and other nutrients to her body following labor and birth to help restore a more balanced body function, prevent “baby blues” and the more serious postpartum depression, increase breast-milk production, shorten healing time, increase maternal energy levels, and provide an over-all feeling of wellness to aid in the transition between pregnancy and the early postpartum period in the woman who has just given birth. Limitations and Disclaimer Bridget Ballenger of BB Birth Services (BBBS) is not a licensed medical professional and therefore not able to diagnose, treat or prescribe for any health condition. Services and fees are for the preparation and encapsulation of your placenta, not for the sale of the pills. No specific benefits or effects are promised. Any benefits will vary from person to person. Some of the ascribed benefits of placenta consumption are supported by research; however these benefits have not been evaluated or approved by the Food and Drug Administration. It is your responsibility to determine whether using placenta preparations may be of benefit to you. Always speak to your care provider regarding any questions about your health, safety and wellbeing. Placenta services are not meant to be a replacement for medical advice or prescription medicines. If you are experiencing symptoms of postpartum depression, low milk supply, or other medical concerns please speak to your midwife or doctor.

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Client Responsibility *

It is the client’s responsibility to notify Bridget as soon after the birth as possible (preferably the same-day as the birth itself) to request pick-up or receipt of the placenta(s) by Bridget at the location previously agreed upon by both parties.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(s), and even spoilage of the placenta(s) which would render it unusable for encapsulation. It is also the client’s responsibility to discuss release of her placenta(s) after her birth from the establishment where she delivers and to ensure proper storage of her placenta(s) in a refrigerator or cooler with the placenta(s) placed on ice until it can be picked up or delivered to Bridget for preparation and encapsulation. Your placenta must not be treated with alcohol, formalin, or any other preservative. Use of these products would render it unusable for encapsulation. It is also the client’s responsibility to inform BB Birth Services of any known blood-borne illness(es) or other health issues that I, Bridget Ballenger, may become infected with through contact of bodily fluids (specifically maternal and fetal blood and amniotic fluid), such as HIV, hepatitis, STD’s, etc.

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Storage and Transportation *Important* *

Your placenta may be kept at room temperature for 3-4 hours. After that it should be refrigerated or otherwise kept cool. If delayed cord cutting or lotus birth is being practiced, ice packs can be wrapped around the placenta to prevent spoilage. If it is going to be more than 3 or 4 days before the placenta can be prepared it should be frozen. A frozen placenta may require an extra one or two days of preparation time to allow for gentle thawing. It is important to note that there may be circumstances under which your placenta cannot be used. Significant abnormalities of the placenta may necessitate your doctor or midwife sending your placenta to Pathology for further examination. It can be requested that only a portion of the placenta be cut off to send to pathology and the remainder frozen pending the outcome. Other conditions, such as signs of infection during labor, may mean that consuming your placenta will not be beneficial to you. If in doubt. I will consult with you before proceeding. It should be possible to claim your placenta after Caesarean surgery. If you are not able to obtain and use your placenta for any reason, I will return all money paid.

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Please indicate which preparation method you would like *

Traditional Chinese Method (TCM) ($300)

Raw Method ($300)

Smoothie Cubes ($125)

1/2 Raw and 1/2 Chinese Method ($300)

Please indicate additional services you would like

A Simple Print (no additional charge)

Umbilical Cord Keepsake (no additional charge)

Photographs (no additional charge)

Salve $40

Tincture $40

Fees *

Fees above include the preparation and encapsulation of the placenta, a storage container, written instructions for storage and handling, and guidelines for taking your capsules. If you are outside of the metro area pick-up/delivery will incur a fee to cover travel unless you arrange to pickup/deliver. The travel fee is $.56 per mile. All Payment is expected when I pick up the placenta. The balance of the total fee shall be paid in full by the time of delivery or pick-up of the finished placenta pills, unless otherwise specified in writing.

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Date *

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