Capsulux

Contract

    Placenta Contract Mother's Name Email Phone Number Estimated Due Date Planned Birth Location What is the best address for delivery of your placenta products? Choose your encapsulation package: (all packages comes with placenta pickup, processing and return of products Encapsulation Method Cord Keepsake
    Would you like a cord keepsake included? This is a piece of your umbilical cord dehydrated into a heart or another shape (depending on length) Storing Placenta
    Store placenta in double bagged 1 gallon freezer Ziploc bag. Place the bag in a airtight container/cooler with ice/icepack.(Hospital may have storage supplies, however, prepare yourself)
    Photography
    We sometimes we take photos of your placenta for record keeping for educational purposes. Do we have permission to take photos for these purposes? Medications
    Are you taking any medications besides prenatal vitamins? If so, list below     Acknowledgments
    My company is not a licensed medical professional and does not diagnose, treat, or prescribe for any health condition. No specific benefits are promised and benefits have not been evaluated by the FDA. It is your responsibility to determine if using placenta products will be of benefit. Placental supplementation is intended solely for person who has birthed the placenta(s).
    It is your responsibility to discuss release of your placenta from your place of birth and to ensure proper labeling and storage of your placenta until it can be picked up or delivered for encapsulation.
    Your placenta should not be treated with alcohol, formalin or any other preservative.

    Please initial the following:
    I acknowledge that the placenta will be stored in a manner that retains its freshness.
    I acknowledge that I am free of Hepatitis B or HIV.
    If either mother or baby has an infection at the time of delivery or within the following 24 hours after delivery - it is important that you let us know. Please initial that you will notify us within 24 hours if an infection is diagnosed.     I understand and agree to the terms of of this contract.
    Signature
    Date

    Thank You For Your Business

    Contact Us

    • +1(510)978 6216
    • info@shopcapsulux.com
    • 500 Capitol Mall, Suite 2350,
      95814 Sacramento CA

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