Please read the following general policies carefully and fill out and check the consent boxes where necessary. All service preferences and health information listed on your intake form have been noted. Please sign and date at the end prior to returning your completed form. Purely Placenta Arts, LLC respects your right to privacy and assure you that all information will be held in the strictest confidence.

Placenta encapsulation is the process of preparing the mother’s placenta after the birth of the baby by steaming, dehydrating, powdering and placing it into capsules for the mother to ingest. OSHA blood-borne pathogen universal safety protocols and proper food handling guidelines are followed closely. The purpose of ingestion of the placenta is to reintroduce beneficial hormones, proteins, and other nutrients to her body following labor and birth to help restore balance and provide an overall feeling of wellness to aid in the transition between pregnancy and the early postpartum period.

I, Sarah Toma (APPAC), am not a licensed medical professional and I am not able to diagnose, treat, or prescribe for any health condition. Services and fees are for the preparation and encapsulation of your placenta, not for the sale of the pills. No specific benefits or effects are guaranteed. Benefits will vary from person to person. Many of the reported benefits of placenta consumption are supported by ongoing research; however these benefits have not been evaluated or approved by the FDA or any other regulatory organizations. It is your responsibility to determine whether using placenta preparations may be of benefit to you.

Whether birthing at home or in a hospital, please ensure that your placenta is kept fresh. It can remain at room temperature for no longer than 2 hours following the birth. After that, (or sooner if possible) it should be refrigerated or otherwise kept cool. If you are practicing some form of delayed cord cutting, ice packs may be wrapped up with the placenta to prevent spoilage for up to 4 hours postpartum. Placenta encapsulation cannot be done after a traditional lotus birth. It is highly recommended that you place a cooler (a styrofoam cooler is acceptable) along with 2 freezer bags in your trunk by 36 weeks. Hospitals generally provide plastic containers, but for a home birth, double bagging the placenta in freezer bags is preferred.

It is your responsibility to discuss release of your placenta from the hospital or where you give birth and to ensure proper storage of your placenta in a refrigerator (below 40 degrees F) or cooler packed with ice until it can be picked up for preparation and encapsulation. *If you are delivering at Norton Suburban, they have a 24hr hold policy and will keep your placenta in a refrigerator at Labor and Delivery. I recommend that you confirm the refrigerator is kept below 40 degrees F for food safety guidelines.

It is important to note that there may be circumstances under 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. Other conditions, such as signs of infection in the mother or baby during labor or within 12 hours, may mean that consuming your placenta will not be beneficial to you. If in doubt, consult your care provider before proceeding. Please be sure to contact me if you or your baby develops an infection within 12 hours of giving birth. I will discontinue the encapsulation process and you will get a refund of all but the non-refundable $50 deposit. We can also plan for different possible keepsakes, or placenta prints if your doctors will release it. It should not be a problem to claim and keep your placenta after Caesarean surgery. To be prepared, it is recommended that your desire to take your placenta be written on a birth plan, and communicated by yourself, spouse, or doula in the event of an unplanned Caesarean surgery. I always recommend restating that you are keeping your placenta after you deliver.

Fees include the pick up of the placenta, preparation and encapsulation of the placenta, and other chosen services, written instructions for storage and handling, guidelines for taking your capsules, and delivery of your capsules. An umbilical cord keepsake is also provided whenever possible. A $50 non-refundable retainer fee is due upon signing this contract. Balance payment can be made by check (to Sarah Toma) or via PayPal for an extra 3% fee. The balance is payable before or upon pick-up of your placenta. If cost is an issue, please ask about payment plan options.

If you choose to terminate this contract after releasing your placenta to me, but before any preparation has begun, I will return your placenta to you for disposal. Your $50 retainer fee is not refunded. There will be no refund and payment will be due in full once preparation has begun, even if you choose not to take the delivery of the finished capsules. If something happens beyond your control that makes the placenta unsuitable for preparing (infection, sent to pathology, etc) then a refund will be given.