Mother's Name* (required)
Estimated Due Date*
Mobile Phone Number*
Email*
Address
City
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Birth Location HomeHospital - RenownHospital - St. Mary'sHospital - Other
Name of Your Midwife or OB/GYN
Do you have any food or environmental allergies? YesNo
If yes, please explain.
Do you have any infectious diseases, such as HIV/AIDS, Hepatitis, Herpes, Lyme? YesNo
Do you have any health complications? Are you taking any medications? YesNo
Traditional Chinese Medicine (TCM) – In this method, your placenta will be steamed with the world’s highest quality therapeutic grade doTERRA essential oils using ginger, lemon, frankincense, and myrrh before dehydrating. This is to enhance its warming properties and help your body use the beneficial properties of the placenta in a deeper way. This method also kills any bacteria and reduces risk of spoilage. However, there is concern about the degradation of the hormones when cooking the placenta.
Raw Dehydrated Method – this method involves slicing the placenta while fresh and raw and dehydrating it immediately. Clients who choose this method more consistently report increased energy as one of the benefits. It is widely held that the hormones are more likely to be bioavailable when the placenta is processed raw. This is the most common method of placenta encapsulation requested.
I choose this method of preparation for my placenta: Traditional Chinese Medicine (TCM)Raw Dehydrated Method
Payment, Cancellation and Refund Policy The above outlined encapsulation process is provided for a fee of $225. A deposit of $50 is required with the signing of the contract. The remaining balance of $175 is required before the delivery of your pills.
You may cancel this contract at any time, but the $50 deposit is non-refundable and covers time spent prenatally and holding aside your space on my calendar.
Please mail $50 deposit to: Reno Tahoe Birth Services, 475 Hill Street, Suite 10, Reno, NV 89501 and make checks payable to RTBS.You can also submit payment via VENMO to @renodoula.
If you cancel after I have picked up your placenta, but before preparation begins I will return your placenta to you upon request and no further payment is required.
If you cancel after the encapsulation process has begun; the balance is due in full and no refund will be given even if you choose not to take delivery of the finished capsules.
Client Responsibilities It is your responsibility to discuss the release of your placenta with your primary health care provider as well as the facility you will be birthing in.
Please bring a small lunch size cooler and two gallon freezer size ziplock bags for storage to the hospital, and keep it on ice until it can be prepared for encapsulation. Your placenta may be kept at room temperature for 3-4 hours following your birth. After that, or as soon as possible, it should be placed on ice or in a refrigerator.
If it is going to be 3 or more days before your placenta can be processed, it should be frozen. A frozen placenta may require 1-2 additional days for processing since it must be gently defrosted prior to being dehydrated.
Do not let the placenta out of your sight. I cannot encapsulate placentas that are examined in a hospital’s pathology lab. Call or text me at 612-819-2852 to arrange a time to pick up the placenta. Please call/text between 7am and 10pm. Encapsulation and delivery takes 1-2 days for a refrigerated placenta. A frozen placenta will take an additional 1-2 days so that it can be safely thawed.
Turnaround Guarantee I do my best to have your placenta back to you as quickly as possible and strive to return your capsules to you within 48-72 hours.
Limitations and Disclaimer I understand and acknowledge that choosing to encapsulate my placenta is not intended to prevent or treat any physical or mental diseases, ailments or symptoms and that I am choosing to encapsulate my placenta for my own personal beliefs, whether it be spiritual or cultural. I also acknowledge that there are no statewide regulations preventing me from obtaining and encapsulating my placenta.
I acknowledge that Ashley Maas of Reno Tahoe Birth Services has provided me with concrete information about both the benefits and risks of placenta encapsulation, and have read all included documents. I understand that my placenta will be handled and encapsulated according to OSHA blood-borne pathogens universal precautions and Nevada Foods Safety and Handling standards, and will be cleaned, cooked, dehydrated and put into pill form in a sanitary and disinfected workspace. Upon receiving my placenta capsules from Ashley Maas of Reno Tahoe Birth Services, I waive any all rights to hold either of them responsible for any undesired effect of consuming the capsules.
I put full trust and acknowledgment that my placenta is being handled in a sanitary and safe environment. I have disclosed to Ashley Maas of Reno Tahoe Birth Services my STD status. I understand that upon receiving my pills Ashley Maas of Reno Tahoe Birth Services is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules.
I do not hold Ashley Maas of Reno Tahoe Birth Services responsible or liable for any transport mishap that is beyond her control (ex. Car accident).
I agree to the preceding Client Responsibilities, Limitations and Disclaimer and Refund Policy by typing my name below.
