Local Sign-Up Form

Part #1: General Information

General Acknowledgements (more information will be provided after signup):

Too far of a drive? Inconvenient meetup times? Would shipping be easier? Click here to redirect to the shipping signup form.

Part #2: Products & Add-ons

Can be updated at a later date if you’re waiting on baby’s gender to be known.

Umbilical cord Keepsake Description: Made to remember the lifeline that connected between mom and baby. Comes in a protective sleeve with baby’s birth statistics on the back & custom storage box.

*No dyes, food coloring, or paints used on the placenta. Placenta is covered with plastic/saran wrap and the vessels are traced individually.

Can be updated at a later date if you’re waiting on baby’s gender to be known.

Tree of Life Placenta Print Description: A stamp of the fetal side of the placenta, creating a ‘tree’-like print. Showing the exact size, shape, and vessel structure of your exact placenta. The tree of life print can be done naturally or with various watercolors (no paint or dye use on placenta). Each print is as different and unique as the placentas themselves. Print will be labeled and laminated.

Tincture Description: Alcohol placenta preservation, extending the longevity of placenta usage and can elicit healing during illness, disease, emotional challenges, or difficult life transitions. Tinctures have an infinite shelf-life when stored correctly, therefore you can receive benefits from your placenta long after the capsules are gone. Tinctures are mainly meant for energy, transitions, hormone stabilization, milk supply, and are helpful in times of returning menstrual cycles and menopause. Most clients choose to have at least one tincture made for long term use.

Salve Description: For topical (skin) application. The placenta compounds & other chosen ingredients for this salve can be very beneficial for things like cesarean scars, perineal tearing, reduce the appearance of stretch marks, wrinkles, sunspots. Can be use as a nipple cream or diaper rash cream. Cradle cap, psoriasis, eczema, baby acne, dermatitis, burns, sunburns, general skin irritations and so much MORE!

Part #3: Agreement & Liability Waiver

If under the age of 18 years, I acknowledge my parent or guardian is providing signed acknowledgement.

Part #4: Bloodwork Submission

Submit answers to pertaining bloodwork and other testing below. No need to get any new bloodwork done, this is normally part of the routine bloodwork done usually from 8-12 weeks gestation. Varying positive results can be discussed whereas encapsulation/certain preparations may or may not be available.

If positive, placenta encapsulation will NOT be available.

If positive, placenta encapsulation will NOT be available.

Varying positive results will be addressed. Since mother is already carrying such infection/disease in her body, encapsulation for some non-active results are still safe with the TCM/Heated method. No RAW products or topical salves will be available.

If positive, you can still utilize placenta encapsulation, added information on monitoring blood sugar will be included.

If positive, you can still utilize placenta encapsulation with the TCM/Heated method (which is our standard preparation method). GBS bacteria is killed after being exposed to 131°F for 30 minutes. The placenta is steamed at 212°F and then dehydrated for approx. 12 hours at 160°F. Therefore any GBS bacteria will be killed by the heat of processing. Many doctors will try to state consumption is not recommend, please be informed. More information will be provided in your printed material. Contact me if you need additional information or articles due to uncooperative staff or difficulty obtaining placenta.

If yes, vinyl gloves will be used.

If any of the above pertain, more information will be provided.

By submitting ABOVE information, I confirm all above information and results are knowingly correct as completed and confirmed by a medical professional or facility. I confirm to report any changes to above results and/or infection that presents itself during labor OR after birth.