Local Sign-Up Form

No Deposit Needed – Payment Not Due Until Placenta Processing

THANKS FOR SIGNING UP !

You will receive information on next steps usually within 12 hours. Please check your junk box if not received. Baby already born? I’m usually able to accommodate last minute decisions to encapsulate, please call/text me directly after filling out this form for proper placenta storage guidelines and expedited communication. My direct line is 636-236-9285.

Part #1: General Information

First Name:

Last Name:

Current Status:(required)

Currently pregnant Baby & placenta delivered. Currently cooled, ready for pickup (within 4 days of birth). Baby & placenta delivered. Currently frozen (6-12 month maximum).

Pregnancy Status: (required)

Singleton pregnancy (one baby) Multiples pregnancy (twins, triplets, etc.)

Baby’s Estimated Due Date / Birth Date: (YYYY-MM-DD)

Email:

Phone Number:

Preferred Contact Method:(required)

Text Email

Street Address:

Street Address Line 2: (Apt #, Suite #, etc.):

City:

State:

Zip Code:

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

I acknowledge & understand placenta needs to be cooled within 4 HOURS OF BIRTH.

I acknowledge & understand placenta will need to be brought to a meet-up location at specified times within 4 DAYS OF BIRTH. If longer, placenta needs to be frozen.

I acknowledge the current meet-up availability are as followed: Warrenton, MO on Mondays, Tuesday 4-6pm / Wentzville, MO on Wednesdays and Fridays 4-6pm / Chesterfield, MO on Thursdays 12-4pm.

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

If referral, event, or other please specify:

Would you like to add an additional contact person to your file to assist with pickup/dropoff?

Yes No

If yes, additional contact person name:

If yes, additional contact person contact information:

If yes, additional contact personal relationship: (i.e. husband, doula, other family member):

Gift Certificate? Referral Code? Enter the code below:

Anything else? (news about baby, additional details, etc.)

Part #2: Products & Add-ons

Baseline Service Fee:(required)

$350: Placenta Capsules ONLY (feel free to bypass the following add-on/preference options for other products) $350+ Plus: Build Your Own Package (any combination of capsules, tinctures, salves, keepsakes below. $150 Keepsake Only Service (placenta to be returned, if desired)

Skip add-on products and preferences now?

Skip: I am signing up to get information and hold my space on your due date calendar and will decide products at a later date. Please scroll down for next steps.

Placenta Capsules: (no addtl. cost included in baseline service.)

Regular Gelatin Capsules (standard) Vegan Capsules Skip: I do not want placenta capsules

Add-On Umbilical Cord Keepsake: $35

Add: $35 Umbilical Cord Keepsake (enter preferance below) Skip: I do not want an umbilical cord keepsake

Umbilical Cord Keepsake Color Preferences: (Photo examples on bottom of page.)

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

Umbilical Cord Keepsake Shape: (Photo examples on bottom of page.)

Heart Shape (standard) Custom Request (enter in field below) (may be limited due to lenght of cord)

Custom Umbilical Cord Keepsake Preferences:

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.

Add-On Tree of Life Placenta Print Keepsake: $35/each

Add: $35 Natural Print (made with the remaining blood on placenta, light pink finish) Add: $35 Watercolor Painted Print (enter color preferences below) Skip: I do not want placenta print(s)

Watercolor Print(s) Preferences: Enter colors desired below, 2-3 colors or shades work best.

*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.

Add-On Placenta Tincture: $35 each

Add: 1 Placenta Tincture Add: 2 Placenta Tinctures Add: Enter quantity in box below for more than 2 tinctures are desired. Skip: I do not want placenta tincture(s)

Tincture quantity desired (if more than 2):

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.

Add-On Placenta Salve: $35 each

Add: 1 Placenta Salve Add: 2 Placenta Salves Add: Enter quantity in box below for more than 2 salves are desired. Skip: I do not want placenta salve(s)

Salve quantity desired (if more than 2):

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!

Get Involved with PHOTOS or VIDEO! (additional charges may apply, see below):(required)

No photos (keep that stuff behind the scenes) Photos of your placenta (sent via text or email) (MOST POPULAR): FREE Photos of your placenta AND step-by-step processing photos (sent via text or email): Additional $35 Social-media style video: Additional $35

Anything else? (Other custom details or requests, variations to standard preparations, etc.)

Part #3: Agreement & Liability Waiver

I have read and agree to sign above MPE Agreement & Liability Waiver?(required)

Yes

Type Full Name As Signature:

Date Signed: (YYYY-MM-DD)

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.

HIV/ AIDS Results:(required)

Negative Positive Unsure / Declined Testing

If positive, placenta encapsulation will NOT be available.

Hepatitis Results:(required)

Negative Positive Unsure / Declined Testing

If positive, placenta encapsulation will NOT be available.

STD / STI Results(required)

Negative Positive Unsure / Declined Testing

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.

Gestational Diabetes(required)

Negative Positive Unsure / Declined Testing Text not yet completed, will update with positive result if obtained.

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

GBS Swab (Group Beta Strep)(required)

Negative Positive Unsure / Declined Testing Text not yet completed, will update with positive result if obtained.

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.

Allergic to latex?(required)

Yes No

If yes, vinyl gloves will be used.

Other Uncommon Situations (check all that apply):

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

Anything else? (other medical conditions, allergies, sensitivities, etc.)

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.

Form will not submit if required fields above are not completed.

Jump to

About Us
Pricing / Packages
Products
Placenta Capsules
Placenta Tinctures
Placenta Salves
Placenta Keepsake Items
Benefits of Placenta Encapsulation
What’s in the Placenta?
Process for Local Clients
Process of Shipping Clients
Sign Up Form
Frequently Asked Questions
Testimonials
Step-By-Step Photo Gallery
Contact Us

Natural	Pearl Coated Pink	Pearl Coated Blue
Metallic Gold Plated	Metallic Rose Gold Plated	Metallic Silver Plated