Name *

First Name

Last Name

Phone *

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Partner's Name

First Name

Last Name

Partner's Phone Number

You'll be busy birthing and taking care of a newborn! I usually communicate with the partner or a family member about pickup, drop-off, and instructions.

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San Francisco Placenta Encapsulation Service: *

Please don't ask your doula to deliver the placenta to my home unless you're planning on paying them an additional fee for their time. Thank you!

$285 option - Includes a curbside hospital pick-up of the placenta and curbside delivery of the finished placenta pills to your hospital or home within 2-4 days from the time of pickup.

$230 option - you have a friend or family member deliver the placenta to my richmond neighborhood home in SF and the capsules will be mailed back to your home with insurance and signature required.

$210 option - you have a friend or family member deliver the placenta to my richmond neighborhood home in SF and also pick up the capsules once completed.

Type of placenta capsules *

Gelatin capsules (no additional fee)

Clear vegan Capsules ($5)

Purple vegan capsules ($10)

Strawberry gelatin capsules ($10)

Which type of bottle would you prefer? *

Glass (not available for mail delivery)

Plastic (safer in the event of accidental dropping)

Optional Placenta Keepsakes (no additional fee)

Emailed placenta photo

Cord keepsake (available if the cord is adequate quality)

Optional add-on services

Twins placenta(s) - $100

Tincture - $50 - Not available for shipping.

Preserved piece in organic alcohol for burial ($15)

Steaming ($100)

Estimated Due Date *

MM

DD

YYYY

Payment Preference *

How would you like to pay?

Venmo (handle Heather-Charmatz)

Cash

Placenta Agreement *

Please read and check all of the below boxes.

I have read the Placenta Encapsulation Agreement, and have asked the necessary questions, making all items stated herein clearly understood. I agree to the terms as stated.

My partner and I DO NOT have lyme disease or any sexually transmitted diseases / blood borne pathogens/transmissible diseases such as Hepatitis B, C or HIV/AIDS.

I understand that to secure placenta services a NON-REFUNDABLE $50 retainer is required.

I understand that the remaining balance is due when the placenta is transferred to Heather. The encapsulation process will not begin without full payment.

I understand that a maternal or fetal infection at or immediately following the time of delivery is a contraindication to encapsulation. An allergic reaction to meds received during labor or a covid infection at the time of birth are also a contraindication. It is not recommended to encapsulate in these cases.

Photo Waiver: In some instances photos of my placenta or placenta products may be taken for educational, promotional, or record keeping purposes. No identifying information will be shared under any circumstances.

Heather is not responsible for lost, held, or damaged packages, mis-delivery errors via carrier or incorrect shipping info. So far there have been no shipping issues reported.