Circle City Birth Services: Placenta Encapsulation
Please complete this form to hire Circle City Birth to encapsulate your placenta. After your form is received, you will be emailed a Square invoice within 24 hours. Please make your deposit of $50 within 3 days of invoice receipt.
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Email *
Mother/Birthing Parent's Name (first and last) *
Your Home Address - Street, City, State, Zip *
Phone Number *
Baby's Estimated Due Date *
MM
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DD
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YYYY
Place of Birth (Hospital or Birth center name. If homebirth please indicate) *
Partner/Family Member's name and cell # (we may communicate with them about placenta pick up if you are sleeping or busy with baby) *
Name of care provider
Is this your first baby? *
If no, have you had your placenta encapsulated before? *
Do you have any infectious diseases such as HIV/AIDS, Hepatitis, Herpes, Lyme? Please be assured, your health information is protected by HIPAA. *
Do you have any health complications? Are you taking any medications? *
Why are you choosing to encapsulate? What possible benefits matter most to you?
Method of Encapsulation preferred *
Include Broth with Steam Prep method (if choosing another method, leave blank)
Clear selection
Type of capsule *
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