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Nationwide Placenta Encapsulation Registration Form


Whether you're currently pregnant or in the midst of labor, it's not too late. Simply, take your placenta home and keep frozen until your placenta shipping kit arrives. If you are 36 weeks along or further, we'll expedite the shipping process to ensure timely receipt of your kit. Feel free to call us at 405-731-5972 with any questions. This process takes just a few minutes to complete.

A $200 deposit is required to schedule our services, which will be applied toward the total cost of $430 for placenta encapsulation. This leaves a remaining balance of $230.


If your placenta becomes unavailable or you choose to cancel services, you will receive a refund minus a $100 scheduling fee. Once you complete this form and your $200 payment is successfully processed (which takes about 1 to 24 hours for review), you’ll receive a scheduling confirmation email with detailed information regarding your placenta and shipping kit.

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):

Can be any color, we try our best to match it.



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

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

What is your estimated due date?
Month
Day
Year
I understand that THE ONLY reason my placenta is unsafe to encapsulate is if I have AIDS/HIV Positive
I understand

We'll get back to you.

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

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. 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.


Day you deliver your baby: bring the ice chest, the 2 biohazard ziplock bags and the leakproof container. You will give the 2 biohazard bags and the leak proof container to your nurse and tell her, “I am taking my placenta home, can you please double bag the placenta inside the two biohazard ziplock bags and place it into the leak proof container.” PLEASE, make sure they double bag the placenta inside the biohazard ziplock bags before placing placenta inside the leak proof container. The placenta has to be double bagged so there aren’t any leakages during transit. If they have their own biohazard bags it’s okay for them to bag the placenta with those and then place it in the container, just make sure they are sealed. Once you delivered your baby, they will have you sign a release form and will then give you your placenta in the leakproof container. You will then place your placenta inside the ice chest and keep it in there with ice, make sure the ice is not melted at least every 4 hours (the hospital will provide ice). Once your placenta makes it home, place it in the freezer (we want to make sure your placenta is rock hard frozen before shipping).


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.



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: 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, you will be entitled to a refund minus a $100 scheduling fee. Note that your shipping kit must be sent back to us before refund can be processed.

There will be no refund and remaining balance will be due once preparation of your placenta has begun, even if you choose not to take delivery of the finished 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.


I agree to taking good care of the ice chest including my shipping kit until the day I ship my placenta to Peace of Mommy Encapsulation.
I agree
I accept the responsibility of gaining possession of my placenta, and notifying my placenta specialist when my placenta has been shipped by sharing tracking number.
I accept
I understand the importance of appropriate handling and storage of the placenta. Improperly handled placentas are susceptible to spoilage​ and all placenta work is done at your own risk​.
I understand
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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