Once you complete this form please give us up to 48 hours to confirm receipt and send your invoice. If you haven't heard from us within that time, please contact us directly.
Please feel free to contact us any time if you have questions.
Contact name (person, other than birth mother, who may contact me about the placenta)
Address Line 2
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Trinidad and Tobago
Bosnia and Herzegovina
United Arab Emirates
Papua New Guinea
Central African Republic
Democratic Republic of the Congo
Republic of the Congo
Sao Tome and Principe
United Republic of Tanzania
Country / Region
Alternate Contact Phone
Baby's etimated due date
Name of Midwife or OB/GYN
Planned birth place
Will this be your first birth?
Please list any food or environmental allergies.
Are you allergic to latex?
Please list any infectious diseases, such as HIV, Hepatitis, Herpes, Lyme. Please note: before processing your placenta, we require evidence of negative results for HIV, Hepatitis B, Hepatitis C.
Do you have any health complications or are you taking any medications other than vitamins?
Do you currently or have you ever struggled with depression or anxiety?
Yes, in the past
Choose your preferred method of encapsulation. Note: Unless chosen otherwise, default preparation is warm. The cost of encapsulation is $275.
Choose your type of capsule. Note: Unless chosen otherwise, default capsules are clear vegetarian.
A photo of your placenta is taken for my records. Would you like a copy via text message?
A free print is included in your package. Would you like a placenta print?
A cord keepsake is included in your package. Would you like a cord keepsake?
Choose your add-on services.
Smoothie cubes $25
Travel fees (pickup and delivery is included for locations within 30 minutes of 08034. Specific costs including tolls will be outlined on your invoice).
Client will deliver placenta -$20
Client will pickup products -$20
Client will deliver and pickup -$40
Pickup and delivery within 30 minutes of 08034 (included)
Pickup and delivery 30-45 minutes of 08034 +$20
Pickup and delivery 45-60 minutes of 08034 +$40
Pickup and delivery 60-75 minutes of 08034 +$60
How did you find us?
Special instructions, comments, or questions:
I take photos of your placenta for record keeping purposes. These photos are available to you at any time. With your permission, I may use these photos for marketing, advertising, education, peer review, or promotional purposes in print or online. Identifying information will not be shared under any circumstances. Do you give permission for photos of your placenta to be used as described?
Payment, Cancellation & Refund Policy
Payment in full is due before delivery of the capsules.
You may cancel this contract at any time but the $50 retainer is non-refundable and covers time spent prenatally and holding aside your space on my calendar.
If you cancel after I have picked up your placenta (or arrived for in-home preparation) 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.
Please type your name here indicating that you agree with the payment, cancellation, and refund policy:
Provide us with a evidence that you have not tested positive for HIV, Hepatitis B or C. We must see evidence of blood results prior to encapsulation.
Talk to your care provider during a prenatal visit about your intended birth place’s policies in regards to releasing the placenta. Sign any forms required and have them placed in your file.
If you are birthing in a hospital: remind your care providers upon arrival that you plan to take your placenta and remind them again during pushing.
Put your placenta into a covered container, secured biohazard bag or double ziplock bag. The container and/or bag must be labeled with your name before I pick it up.
It can remain at room temperature for up to 2 hours following the birth. Refrigerate or put it on ice as soon as reasonably possible. Improperly handled placentas are susceptible to spoilage.
Do not let the placenta out of your sight. I cannot encapsulate placentas that are examined in a hospital's pathology lab.
Text message me at 856.313.5466 after the birth to arrange a time to pick up the placenta. If overnight, I will respond before 8 AM to arrange for pick up.
If you are not able to contact me within 4 days of the birth, freeze the placenta until you are ready for pickup.
Prior to pickup, please alert me via text message if there is anything out of the ordinary that I need to know (maternal or infant fever, meconium present at birth, etc).
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.
Type your name here indicating that you agree to adhere to the client responsibilities.
I do my best to have your placenta back to you as quickly as it can safely be prepared. This is usually the day after I pick it up and sometimes the day following. Clients who sign this contract before labor begins receive a turnaround time guarantee. If I deliver your capsules later than the third day after pickup you will receive a discount of $25. I may choose to have a backup encapsulator process your placenta if I have received more than one placenta at a time so that I can meet the turnaround deadline. Clients who contact me for encapsulation after labor begins will receive second priority to contracted clients and do not receive a turnaround guarantee, although I will still return your capsules as quickly as is safely possible.
Type your name here indicating that you understand the turnaround guarantee.
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 consume 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 Tiff Hare, Karma 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 bloodborne pathogens universal precautions and NJ Food Safety and Handling standards, and will be cleaned, cooked, dehydrated and put into pill form in a sanitary and disinfected work space. Upon receiving my placenta capsules from Tiff Hare, Karma Birth Services, I waive any and all rights to hold them responsible for any undesired effect of consuming the capsules.
I put full trust and acknowledgement that my placenta is being handled in a sanitary and safe environment. I have disclosed to Tiff Hare, Karma Birth Services my STD status. I understand that upon receiving the pills, Tiff Hare, Karma Birth Services is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules.
I do not hold Tiff Hare, Karma Birth Services responsible or liable for any transport mishap that is beyond her control (ex. car accident or detainment).
Type your name here indicating that you agree to the limitations and disclaimer outlined above.