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Placenta Encapsulation Registration Form for Oklahoma City and Surrounding.


Whether you’re currently pregnant or already in labor, it’s never too late to book with us! We do our best to accommodate everyone, no matter how far along they are in their pregnancy. Feel free to call us at 405-731-5972 with any questions.


This form takes just a few minutes to complete. A non-refundable deposit of $75 is required to reserve your spot and secure your placenta pickup. Your deposit will be applied toward your total service fee.

Final Payment. The remaining balance is due by the time of placenta pickup or within 24 hours after.

Once we review your form and your $75 payment is successfully processed, you'll be emailed a scheduling confirmation email with placenta storage instructions and more information regarding your delivery.

Please check all the boxes that apply. Boxes that are left unchecked will not be added to your order. Once we review your form, we'll send you an invoice with remaining balance.
Umbilical Cord keepsake Color (if applicable):

Leave blank if not applicable.

Do you consent to receiving booking related text/call communications Peace of Mommy Encapsulation, at the number provided?
Yes
No
Multi-line address

If you don't know yet, or don't remember leave blank.

What is your estimated due date?
Month
Day
Year

We understand due dates are not 100% accurate. We just need an estimated date.

Enter Referral Code & name of the person who gave you the gift voucher.

We'll get back to you.

When dropping off your placenta products, would you like us to hand them to you personally, or would you like us to leave them outside your door and then receiving a drop off confirmation text? We always make sure you’re home from the hospital before deli
Drop off
Hand them to me
I understand that THE ONLY reason my placenta is unsafe to encapsulate is if I have AIDS/HIV Positive
I understand

CLIENT RESPONSIBILITY: It is your responsibility to discuss the release of your placenta the day of your delivery with your primary health care provider as well as the facility you will be birthing in the day of your delivery. Your placenta may be kept at room temperature for 3­-4 hours following your birth. After 4 hours it needs to be in a sealed container or ziplock bag, and it needs to be chilled at 30-40 degrees (hospitals will provide their own containers and ice for your placenta).


How to go about asking to keep your placenta: Some women like to let their health providers know ahead of time but it's not necessary. The day you deliver your baby, before you go into labor simply let your nurses know that you'll be keeping your placenta and that you've made arrangements for someone to come pick it up after your delivery. You do not have to ask for permission to keep your placenta. IT IS YOUR ORGAN!


Some hospitals will keep your placenta in a fridge until we pick it up, if that is the case make sure the hospital labels the container with a note that says "DO NOT TAKE-PATIENT IS TAKING HOME." We recommend bringing your own cooler with you so your placenta does not leave your room to reduce chances of your placenta being misplaced or being taken away.


It is your responsibility to notify me when you are in labor and again as soon as possible after birth to make arrangements for transfer of your placenta to me. Improperly handled placentas are susceptible to spoilage.


It is important to note that there may be circumstances under which your placenta can not be used. Significant abnormalities of the placenta may necessitate your doctor or midwife sending your placenta to Pathology for further examination. Please call us as we can consult with you before proceeding with any decision they make regarding your placenta.


Our placenta pick up hours are Monday-Sunday from 9 am to 6 pm. UNLESS your hospital has a specific time frame in which the placenta needs to be picked up. If they schedule you for induction or C-Section please let us know the date and time. If possible, let us know when you’re about to go into labor and once again when your placenta is ready for pick up. Text/Dm or Call us when your placenta is ready for pick up (405)731-5972. We will give you an estimated time in which your placenta will be picked up.


LIMITATIONS AND DISCLAIMER: We are not licensed medical professionals and We are 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. Benefits will vary from person to person. Many of the benefits are well supported by evidence based research; but none have been evaluated or approved by the FDA (all holistic medicine is usually not FDA approved, such as dietary supplements, herbal supplements, and natural remedies).


Refunds & Cancellations:  In the event your placenta is unavailable to you (ex. sent to Pathology and not released), if you choose to terminate services, or if your placenta has been contaminated with a bacterial infection.

• The $75 deposit is non-refundable, as it reserves your spot and covers preparation and payment processing fees.

• If your placenta has already been picked up or encapsulated, no refunds can be issued, as your service is already underway and materials have been used.


By signing below, my permission is granted for your specialist to transport your placenta for preparation and delivery of completed capsules. Your placenta will be handled and encapsulated according to OSHA bloodborne pathogens universal precautions and Food Safety and Handling standards. Your placenta will be cleaned, steamed, dehydrated and put into capsule form in the sanitary and disinfected work space indicated above. I understand that upon receiving the pills, my placenta specialist is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules. Peace of Mommy Encapsulation does not determine whether my placenta should be consumed and makes no guarantee of my personal results from the capsules. The capsules should not be taken during times of illness, such as the common cold, flu, or mastitis. I understand that taking the capsules in any manner other than as labelled can have undesirable results. We keep this document on file as a record of our agreement. No copies will be released to any third parties.


Registration deposit payment
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Spring Creek Village Shopping Center, 1489 E 15th St Suite 116E, Edmond, OK 73013 

Booking online only - No Walk-ins Accepted

405-731-5972

Placenta Capsules do not replace medical care and should not be used to treat severe anemia, inadequate milk supply, and severe ppd.



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