Name *

First Name

Last Name

Which type of processing would you prefer? (See Placenta Services page for more details on each.) *

Encapsulation (using Traditional Chinese Method)

Raw method (to be used in smoothies or whatever you prefer)

Half/Half

May I take and use photos of your placenta for education, advertising, and marketing? (Your privacy will be protected, no identifying information will be available.) *

Yes

No

Client Responsibility *

Please check that you are aware of each point.

My placenta cannot be processed if I am HIV, Hepatitis B, or Hepatitis C positive.

My placenta cannot be processed using the raw method if I am GBS positive (encapsulation is ok).

My placenta cannot be processed if I show signs of infection during labor, or if they need to send it to Pathology.

I will take proper care to ensure that my placenta is placed on ice or refrigerated within 1-2 hours after birth.

Jill will transport my placenta from my place of birth to my home to process.

I will communicate with Jill regarding how she can have access to my home, and I am aware that it is a two day encapsulation process.