Name: Breathe Birth Care
Address: Mapleton, UT, 84664
Telephone: 801-616-6000

Placenta Encapsulation

Placenta Encapsulation Intake Form

Please fill out the form below to get started. Fields marked with an asterisk (*) are required.

Name

First Name*Last Name*

Pronouns

Email*Phone Number*

If we need to contact you about your placenta, do you prefer a text message or a phone call?*

Text Message Phone Call Email

Home Address*CountryAddress Line 1*Address Line 2

City*State*ZIP Code*

Name of support person we may contact about your placenta

First NameLast Name

Please List Their Phone Number (if applicable)

Planned Birth Location*CountryAddress Line 1*Address Line 2

City*State*ZIP Code*

Estimated Due Date*

Package Option*

There are two package options, please choose one.

All Inclusive Pickup/Dropoff (Base fee of $250 + any additions) You Pickup/Dropoff in Mapleton ($225 + any additions)

Capsule Choices*

Tincture Options*

Cord Keepsake (free if in combination of encapsulation, $25 on its own)*

Yes No

Placenta Print (+ $15 if in combination of encapsulation. $30 on its own)

The placenta often is compared to the tree of life, using the natural fluids I do a stamp of your placenta to a piece of art paper. This art piece is beautiful to frame and display or put in baby's scrapbook

Yes No

Herbal Additions

Nipple Balm ($10) Postpartum Bottom Spray ($10) Infant Massage Bar ($10) Postpartum Sitz Bath Herbs 12ct ($10)

Contract Agreement

Placenta encapsulation is the process of preparing the birthing parent's placenta after the birth of their baby by dehydrating, powdering, and placing it into consumable capsules. All processes are done with respect of that placenta and in a sanitary environment. Kalli Chason and Morgan Shipp adhere to strict OSHA guidelines and follows proper food safety standards. The purpose of ingestion of the placenta is to reintroduce beneficial hormones, proteins, and other nutrients to the body following labor and birth to help restore physical and emotional balance, prevent or lessen the risk of "baby blues" that may lead to postpartum depression, increase human milk production, shorten healing time, increase energy levels, and provide an overall feeling of wellness to aid in the transition between pregnancy and the early postpartum period.

Limitations and Disclaimer:

We are not licensed medical professionals and we are 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 promised and any benefits will vary from person to person. Some of the ascribed benefits of placenta consumption are supported by research; however these benefits have not been evaluated or approved by the United States government or the Food and Drug Administration. It is your responsibility to determine whether using placenta preparations may be beneficial to your wellbeing postpartum.

Client Responsibility:

A $50 retainer is required to hold your due date for us to be on call. We will be on call for your birth from 37-43 weeks of pregnancy once payment is received. The entire payment is due in full by 38 weeks of pregnancy. If the payment has not been made, Kalli Chason and Morgan Shipp may pickup the placenta, but will not begin processing until payment has been received.

It is the Client's responsibility to inform Kalli Chason and/or Morgan Shipp within 24 hours of birth, ideally immediately postpartum, so that we can arrange to come pickup the placenta. Once the placenta has been picked up, as long as payment has been received, it will be processed in no more than 72 hours (more commonly 24-48).

Placenta Transport Preparation:

In order for the placenta to be processed, it must be kept fresh. A placenta can be kept at room temperature for no more than 3-4 hours, on ice for no more than 24 hours, in a refrigerator for no more than 3 days, and in a freezer for no more than 6 months.

There are very few reasons a placenta cannot be processed, these reasons are most commonly, a placenta being taken to pathology or an active infection in birthing parent or baby. Meconium and GBS+ results are NOT contraindications for encapsulation and ingestion.

Refund Policy:

We refund completely for maternal or fetal demise. We refund all but the retainer of $50 for Placenta's that are unable to be ingested. We do not refund for Placenta's that are not kept fresh due to negligence.

If a placenta pick-up or drop-off is outside of Utah and Salt Lake counties a $15 service fee is added for both pick-up and drop-off ($30 if both are outside of these counties). If you wish to wave this fee, you are welcome to drop-off, pick-up, or both at our American Fork location.

Limitations and Disclaimer:

Placenta Transport Preparation:

Refund Policy:

If unforeseen circumstances prevent Kalli Chason and/or Morgan Shipp from picking up within 24 hours of being notified of delivery, a full refund will be provided unless otherwise discussed.

I have read, understood, and agreed to the above information. I accept the responsibility of gaining possession of my placenta, and notifying my placenta specialist within 24 hours of my birth. I understand the importance of appropriate handling and storage of the placenta. By signing below I authorize Kalli Chason or Morgan Shipp to prepare my placenta for my own personal use. provide an overall feeling of wellness to aid in the transition between pregnancy and the early postpartum period.

Electronic Signature*

Coupon Code