Placenta Encapsulation Registration Form

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If you are ready to register, please submit this form and I will respond shortly. If you still have more questions, please email or call Meriah at 310-560-8599 or placentaservice@gmail.com. Try to register in advance so you have time to get instructions, guidance, and time to prepare.
*** This information you provide will be kept confidential, between you and Mama Love Placenta Encapsulation/Meriah Davis.

Mother's Name *

Due Date *

YYYY

Mother DOB

YYYY

Partner's Name

Scheduled C Section Date?

YYYY

Phone Number *

Email *

Home Address

Where are you planning to give birth? Or did you already give birth?

Name of Baby

Sex of Baby

Male

Female

Multiples

Clear selection

Please select which applies to you.

This is my first baby

This is my 2nd baby

This is my 3rd, 4th, 5th+ baby

Clear selection

Do you have any infectious diseases, such as HIV/AIDS, Hepatitis, Lyme? *

Yes

Maybe

Please list any infectious diseases you have or may have.

Please list any complications you are experiencing with this pregnancy.

Please list any medications you have been taking during this pregnancy.

I am interested in the following along with my Placenta Capsules at no extra charge. (Check all that apply).

Placenta Tincture (to use after 6 weeks and will be good for many years). More info: https://docs.google.com/document/d/1VxH0y_QQkH_wsinlD7ZbpQc6DaXFKVmCKu2OVwVZlZo/edit?usp=sharing

Placenta Print. Food dye applied to placenta and pressed to water color paper.

Umbilical Cord Keepsake

Ebook- Essential Oils for New Moms

PeriSpray- soothing spray for perineum. Distilled water + Lavender + Frankincense

Raw pieces of placenta (thumbnail size, not encapsulated). For smoothies (frozen, for you to blend in a berry smoothie).

Which preparation method do you prefer? For more info please see: http://bit.ly/HeatedOrRaw *

SEMI RAW- Not truly "raw" since it will be dehydrated at 160 degrees. Traditionally "raw" food is heated no higher than 118 degrees.

HEATED- Steamed for a few minutes before it goes in the dehydrator. If there is any meconium, I will use this method.

Half and Half

I experienced the following after one or more of my previous births. (Check all that apply).

Challenging Physical Recovery

Challenging Emotional Recovery

Baby Blues

Post Partum Depression

Low Milk Supply

Post Partum Anxiety

No problems

I'm not sure

Other:

Is there anything you would like to share with me about your previous postpartum recovery/ recoveries?

Why are you choosing to ingest your placenta? What benefits are you looking forward to?

Will you be needing a referral to any other services?

Anything else?

How did you find Mama Love Placenta Encapsulation?

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