Placenta Encapsulation Contract

If birthing at Troy Beaumont, all releases from OB/Midwife and Pediatrician MUST be completed before agreeing to a time to pick up your placenta. A $50 travel fee will be included if a second trip for pick up is required due to releases not being completed or other hospital policy circumstances preventing placenta release at initial pick up.

If birthing at Troy Beaumont, all releases from OB/Midwife and Pediatrician MUST be completed before agreeing to a time to pick up your placenta. A $50 travel fee will be included if a second trip for pick up is required due to releases not being completed or other hospital policy circumstances preventing placenta release at initial pick up. I Agree Not Applicable - Not birthing at Troy Beaumont

I agree:

I agree: • I will ensure proper storage of my placenta in a refrigerator or cooler with the placenta indirectly placed on ice, within two hours of birth of the placenta, until it can be transferred for preparation and encapsulation. I understand that by not properly storing my placenta after the birth of my baby my placenta may be susceptible to spoilage no longer be a candidate for encapsulation. See below for image of proper storage techniques. Replacement of ice upon melting is required for proper storage. • I will contact The Grosse Pointe Doula, LLC after my baby is born to arrange for pickup of my placenta and will do everything within my client responsibilities in 24 hours of the birth. • I will discuss the release of my placenta with my hospital and care provider PRIOR to delivery. I understand that obtaining my placenta from my chosen place of birth is my responsibility. • I will sign any release forms prior to the arrival of The Grosse Pointe Doula, LLC or its representative. • I agree that I have never been diagnosed with and am not infected with any of the following diseases: HIV, hepatitis, genital herpes breakout, gonorrhea, syphilis, or chlamydia, that could place Margaret Rodeghier or any others who may come in contact with my bodily fluids (specifically maternal and/or fetal blood and amniotic fluid) at risk. If in doubt, I will consult my care provider before proceeding.

Photo Release Options

Photo Release Options I give The Grosse Pointe Doula, LLC permission to take and use photographs of my placenta for advertising, marketing, educational purposes, and/or social media. I would like to have images taken of my placenta sent to me

Other Options:

Other Options: I am vegan/vegetarian. Please use vegan capsules I would like to keep my umbilical cord as a keepsake I would like Reiki provided to my placenta and capsules I am interested in receiving additional lactation support services through MiLK (this is not included in encapsulation fees)

Placenta Encapsulation Contract