Thank you for choosing Nightingale Birth Center to provide your placenta services. Please fill out the following client intake information and type your name & the date at the bottom as an electronic signature. Once you submit this form, you will receive an email confirmation within 24-48 hours that you have been placed on our calendar, along with detailed instructions on safe handling of your placenta until pickup. Payment is due when we pick up your placenta at your place of birth. 

Request for Placenta Encapsulation Services

Please read below, fill in the requested information, and type your name and date at the bottom as an electronic signature before submitting.

I have asked Nightingale Birth to prepare my baby's placenta in capsule form for my own personal use.
As a condition of this service, I make the following assertions:
I agree that...

  • I am paying for the encapsulation preparation service only, which is not clinical, pharmaceutical, or intended to diagnose or treat any condition. 

  • My placenta does not contain any transmittable diseases such as Hepatitis-B, -C or HIV/AIDS.

  • The placenta will be handled in a manner appropriate for safe food preparation following the birth until pick up for preparation. 

  • If I have any questions I will contact Nightingale Birth directly for more information/clarification. 

  • I authorize the release of my placenta to Nightingale Birth and I authorize Nightingale Birth to transport my placenta for preparation.

  • The information provided about placenta encapsulation has not been evaluated by the Food and Drug Administration.  

Name *
Name
Phone *
Phone
Partner's Phone
Partner's Phone
Expected Due Date *
Expected Due Date