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Reserve Your Due Date Here!

It is best to reserve your due date as soon as you can; your placenta specialist takes on only a certain amount of clients per month. Once you submit your forms, you will be contacted by Brittany to schedule your consultation.
Unavailable days for placenta pick up:
11/8/18 to 11/12/18

Intake Form

Fill out, click & submit to proceed with your placenta service.

* Indicates required field

Expectant Mother's Name *

First

Last

Expectant Mother, are you a surrogate? *

Yes No

What is Your Preferred Language? *

Do You Speak Any English? *

Mother's Estimated Due Date *

Mother's Phone Number *

Mother's Email *

Mother's Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Babies Name *

Babies Gender *

Female Male Surprise! Two or More Bundles

Planned Location of Birth *

Alternative Contacts Name *

Alternative Contacts Phone Number *

Relationship *

What Placenta Package would you like? *

In-Home Encapsulation Take it Easy Keep it Simple

Would you like an optional Umbilical Cord Keepsake? *

Yes! Heart Shape Yes! The word LOVE Yes! Something else No. Encapsulate cord with my placenta

How did you hear about us? *

Please list any medical conditions, pharmaceutical medication(s) or supplement(s) you currently take and any allergies you may have. *

Are You Currently Negative for STDs? *

Yes, I am negative for all STDs No, I am positive for (1) or more STDs

You will email, text or personally show Brittany Noelle your STD results or a doctors note stating that you are currently negative for STD(s) before your placenta is prepared. *

Yes, I will provide proof of my STD status No, I will NOT provide proof of my STD status

Contract

Click button YES if you agree to Or NO you do not agree to

*I am not a licensed medical professional such as a care provider or physician and I am not able to diagnose, treat or prescribe for any health condition. Services and fees are for the service of encapsulating your placenta, NOT for the sale of the capsules. Each woman will react to her placenta capsules in different ways. Some of the ascribed benefits have not been evaluated or approved by the United States government or FDA. It is your responsibility to determine whether using placenta capsules can be beneficial to your wellbeing postpartum. *

YES NO

*It is your responsibility to inform me of any known blood borne illness(es) or other health issues (such as HIV, Hepatitis etc.) that could place me or any others who may come in contact with your bodily fluids (specifically maternal and fetal blood as well as amniotic fluid) at risk. Some specific sexually transmitted diseases such as hepatitis or herpes may preclude me from offering placenta encapsulation in my home. *

YES NO

*My responsibilities include maintaining client confidentiality, committing to preparing and returning your capsules within 72 hours of receiving your placenta (usually 24-36 hours) and upholding the highest standards of cleanliness, safety and quality of professional placenta preparation services. *

YES NO

*It is important to understand that there may be circumstances in which your placenta cannot be used. Significant abnormalities of the placenta may necessitate your doctor or midwife sending your placenta to Pathology for further examination. Once the placenta has been released to Pathology, I will NOT be able to encapsulate without an additional waiver. Other conditions, such as signs of infection in the mother during labor, may mean that consuming your placenta could be harmful to your health. I will always consult with you prior to making a choice on whether or not your placenta is viable for ingestion. It is important that you let me know if you have any health concerns or conditions which may affect the health of your placenta or the health and safety of others who may come in contact with your placenta. *

YES NO

In-home encapsulation, it is your responsibility to be watchful & careful of the dehydrater once your placenta is dehydrating in your home. You must be sure that you or anyone living/visiting in your home does NOT touch, move or unplug machine without first contacting your placenta specialist. If for some reason your dehydrater is unplugged, turned off, moved etc. it may preclude me from finishing the encapsulation process for safety & health reasons and you will not be entitled to a refund. If for some reason there is an electrical power outage or dehydrator machine failure and your placenta is non-consumable then you will be entitled to a $200.00 refund once investigation is finished. Any travel fees are non-refunadable. *

YES NO

*If I have already taken possession of your placenta and you choose to not go forward with services, I will return your placenta to you and you will be given a full refund (less) minus $100.00 (Any travel fees are non-refundable) for consultation, handling & travel. If for whatever reason you decide to forgo my services before I have taken possession of your placenta, you will be given a full refund (less) minus $50.00 for consultation & travel. There will be NO REFUND once preparation has begun, even if you choose not to take delivery of the finished placenta capsules/goods. *

YES NO

*I have read, understood and agreed to the above information. By electronically signing below I authorize the release of my healthy placenta to Brittany Noelle; The Joyful Tree for purposes of placenta encapsulation services and keepsake preparation for my own personal use. *

I Agree to I do NOT Agree to

Sign Your Name by Typing it *

Date Signed *

Liability

*I understand and acknowledge that in accordance to my state laws and bylaws, 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 etc. I acknowledge that my placenta specialist has provided me with concrete information about both the benefits and risks of placenta encapsulation, and I have read all included documents. I understand that my placenta has been and encapsulated according to OSHA and State Food Safety and Handling standards, and has been cleaned, cooked, dehydrated, and put into pill form in a clean and sanitary work space. Upon receiving my placenta capsules from my placenta specialist, I waive any and all rights to hold the specialist responsible for any undesired effect of consuming the capsules/tincture/placenta food. (Smoothies, chocolates and prepared placenta meals etc.) This may include an oversupply in milk, hormonal shift, anxiety or sleeplessness; these side effects are rare, but have been reported. I agree to contact my placenta specialist immediately if and when I experience any of these side effects. My specialist agrees to complete (2) postpartum follow-ups until 6 weeks postpartum. I do not hold my placenta specialist responsible or liable for any transport mishap that is beyond their control (ex. Car accident or detainment), and understand that I am choosing to have the specialist encapsulate my placenta. *

I Understand & Agree I Do Not Agree

Where would you like your placenta prepared? *

*If my placenta is not encapsulated in my own home, I put full trust and acknowledgement that it is being handled in a sanitary and safe environment. I put trust and faith that my placenta specialist has been trained and certified to correctly prepare placenta remedies. I have provided my placenta specialist with recent blood documentation stating that I have been tested for STD’s and the results were negative. Universal precautions for sanitizing are the same with each client, I understand and trust that my specialist retains blood work records for each client and that I am protected. I understand that upon receiving the pills, my placenta specialist is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules. *

I Understand & Agree I Do Not Agree

Sign Your Name by Typing it *

Date Signed *

Submit

Servicing the following areas:
Orange County, Los Angeles County, San Bernardino County & Riverside County.

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The Joyful Tree Placenta Encapsulation & More has not been evaluated by the FDA and are not meant to prevent, treat or diagnose any disease, illness or symptoms. Clients understand that they are assuming all risks and benefits on their own profound belief and that The Joyful Tree Placenta Encapsulation & More is merely a service. © 2014 by The Joyful Tree. All rights reserved.