Placenta Encapsulation Intake Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred Method of Communication (text, call, email) What services are you interested in? * Placenta Encapsulation Placenta Prints Cord Keepsake (if possible) Estimated Due Date * MM DD YYYY Where are you delivering? * Please list any medications taken during pregnancy. * Please list any herbal remedies taken during pregnancy. * Are you a smoker? * Yes No Do you have any STIs or blood transferable diseases? (ex: HIV or Hepatitis) * If this is not your first child, did you have any problems previously with Postpartum Depression? Would you like the Raw Method (hormone dense, high nutrients, large number of capsules) or Steamed Method (recommended if fever develops during labor, mothers with a history of pre-eclampsia or high anxiety individuals) for Placenta Encapsulation? * Raw Method Steamed Method Thank you!
