Womb Service Placenta Encapsulation Registration Form (2024)

The fee for placenta encapsulation is $300
This includes on call pick-up of your placenta immediately after your birth, encapsulatiing your placenta and delivery of your capsules the day after your birth. NO HIDDEN CHARGES.

This form should take just a few minutes to fill out. You will get an email confrimation within one day of registration. If you have immediate questions or you have gone into labor before you have been able to fill out this form, please call me at 619 398 5683 and I can help!
Ideally, please register before 37 weeks so I can help you properly prepare for your hospital's policies.

Mother's Name (first and last)
Partner's Name
Due Date Due Date / MM / DD YYYY
Phone Phone - ### - ### ####
Alternative Phone Alternative Phone - ### - ### ####
Email
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Where are you planning on giving birth?

Where are you planning on giving birth? Sharp Mary Birch (San Diego) Sharp Grossmont (La Mesa) Kaiser (Clairemont Mesa Blvd) Scripps Encinitas (Encinitas) Scripps Memorial (La Jolla) Scripps Mercy (Hillcrest) UCSD Jacobs (La Jolla) UCSD (Hillcrest) Balboa Naval Hospital (San Diego) Kaiser Palomar (Escondido) Sharp Chula Vista (Chula Vista) A Family Affair Birth Center (Poway) Home birth within 30 miles of 92107
Name of your baby (if you would like to share)
Sex of Baby

Sex of Baby Female Male Unknown Prefer not to say
Name of birth doula (if you have one)
Name of OBGYN or midwife
Please tell me about your upcoming birth. Check all that apply.

Please tell me about your upcoming birth. Check all that apply. This is my first baby This is my second baby This is my third baby This is my fourth/ firth/ ++ baby I'm planning a vaginal birth I'm planning a cesarean birth (belly birth) I'm planning a VBAC I already know my birth is going to be scheduled (either an induction or cesarean) I'm not planning a scheduled birth. I'm planning on going into labor on my own.
Please list any complications you are experiencing with this pregnancy.
Please list any medications you have been taking with this pregnancy.
What benefits of placenta encapsulation are you most looking forward to?
Is there anything you would like to share with me about your previous postpartum recovery/ recoveries?
I am interested in the following referrals for my prenatal or postpartum wellness & education. Please check all that apply.

I am interested in the following referrals for my prenatal or postpartum wellness & education. Please check all that apply. Birth doulas Postpartum doulas Lactation Consultants Breastfeeding Support Groups Massage therapists Chiropractors New Mother Support Group Mommy and Me Classes Housekeepers Meal Service
How would you like your placenta prepared for encapsulation?

How would you like your placenta prepared for encapsulation? Basic Heated (cleaned, steamed, sliced, dehydrated and encapsulated) (recommended) Raw Prep (cleaned, sliced, dehydrated and encapsulated) (I will double check to see if you are a candidate for this if you want the raw method) I may need help deciding
Are you Group Strep B positive? You will know this only after the culture which is usually taken at 36 weeks.

Are you Group Strep B positive? You will know this only after the culture which is usually taken at 36 weeks. Yes No Not sure yet
After preparation, your placenta powder is put into capsules. What type of capsule do you choose?

After preparation, your placenta powder is put into capsules. What type of capsule do you choose? Clear vegetarian capsules Red colored gelatin capsules Strawberry flavored gelatin capsules (+$10) Mint flavored gelatin capsules (+$10)
Would you like me to take photos of your placenta and email them to you? (NO EXTRA CHARGE)

Would you like me to take photos of your placenta and email them to you? (NO EXTRA CHARGE) Yes, please email them No, definitely not I'm not sure but please take some and I can decide later
What shape would you like me to create from your baby's umbilical cord? (NO EXTRA CHARGE)

What shape would you like me to create from your baby's umbilical cord? (NO EXTRA CHARGE) Spiral Heart I definitely do not want a cord keepsake
Are you interested in having a tincture made from your placenta? (This is an optional add-on)

Are you interested in having a tincture made from your placenta? (This is an optional add-on) No tincture. I just want the pills One 4oz tinctures (+$35) Two 4oz tinctures (+$45) I'm not sure. I need more information.
Are you interested in having a placenta print on water color paper? (This is an optional add-on)

Are you interested in having a placenta print on water color paper? (This is an optional add-on) No Yes (+$20)
How would you like Womb Service to receive your placenta after the birth?

How would you like Womb Service to receive your placenta after the birth? Pick up right from your hospital room immediately after the birth (INCLUDED) I will send someone to deliver the placenta to you after the birth for $50 off
How did you hear about Womb Service?

How did you hear about Womb Service? I know someone who used your services Google or other internet search Yelp Health care provider Birth worker
Thank you so much for choosing me to be your encapsulation specialist. Whom do I have to thank for referring you to Womb Service?
Do you give your permission for photos of your placenta to be used as described above?

Do you give your permission for photos of your placenta to be used as described above? Yes, go ahead as long as my info is not included. No. Do not use the photos.
How would you like to pay? Payment can be made at the birth and is not required ahead of time!

How would you like to pay? Payment can be made at the birth and is not required ahead of time! ApplePay Venmo ApplePay Paypal Zelle Square Cash
Are you planning on seeking insurance reimbursement for this service?

Are you planning on seeking insurance reimbursement for this service? Yes, I want to try and I heard it could be covered. Maybe! Please send me information! No, I'm not interested.