Complete this form, to reserve your spot for our Placenta Encapsulation Services. If you have any questions, please contact us at (719) 661-9028 prior to submitting your form.
Payment is DUE UPON RECEIPT OF YOUR PLACENTA. Cash, Check and Credit Card are accepted. Insurance will not cover encapsulation. HSA cards work just fine.
Once you have filled out and submitted this form, you will receive a confirmation and specific information you may need to ensure proper handling/preparation of your placenta.
Please note, due to certain hospital policies, it may not be possible to pick up your placenta prior to your discharge.
Current info about area hospitals:
St Francis Medical Center:
Your placenta will be taken away immediately following delivery. Be sure to let your nurses know that you plan to keep it, so it will be properly stored. The placenta will be double bagged, labeled and stored in the L&D refrigerator until you are your baby are discharged. At that time, it will be released directly back to you, as long as you remember to ask for it before you leave. Hospital pick-up will not be possible in this case. Instead, you will need to either bring your placenta home with you and store it in your refrigerator, for a home pick-up, or drop it off with me.
Memorial Hospital (North and Central):
Your placenta will be taken immediately after birth. Be sure to let your nurses now that you plan to keep it, they will have release forms for you to sign. From there it will be put in a sterile plastic container, bagged, labeled and kept in cold storage until you and your baby are discharged. They will not release it to you, prior to your discharge, so hospital pick-up is not an option. If you choose to have your placenta picked up, you will need to take it home with you (put it immediately in your refrigerator), and make arrangements for an in home pick-up. Otherwise you are welcome to drop it off with me, either on your way home, or at a later date.
Evans Army Community Hospital:
Evans is very relaxed about releasing your placenta to you immediately after birth, as long as you let them know you want to keep it. They will usually package it in either a small plastic tub, or double bag it in biohazard safe bags. You will need to bring a small/medium sized cooler with you to the hospital, so that you can store your placenta on ice while you are there. Effective immediately...due to increased security restrictions on Ft Carson making it difficult for civilians to travel on post, in-hospital pick-up is no longer an option. If you select "pick-up", arrangements can be made to meet somone in the parking lot at the Visitor's Center, or at a private home later.
Mountain Midwifery Center:
The midwives at MMC are very willing to release your placenta to you, following your birth. You will need to bring 2 of the gallon sized zip-lock bags, and a small cooler with you, for transport home. (If you require transport to the hospital for your birth...besure to let the hospital staff know you plan to keep your placenta.) Pick-up is not an option, since MMC is not located in Colorado Springs. You can either drop your placenta off with me on your way home, or put it in your refrigerator and make arrangments for a home pick up at a later date.
Planned Home Birth:
Be sure to mention to your midwife that you plan to keep your placenta for encapsulation. You will need to have 2 of the gallon sized zip-lock bags for storage. Your midwife (or in the case of Free-Birth, your partner) will need to double bag and put the placenta in the refrigerator, for safe keeping. If you transfer to the hospital for your birth, be sure to let the hospital staff know you plan to keep your placenta. Pick-up is available in Colorado Springs only. (If you live on a military base, and are planning a homebirth, please see the info listed above for Evans Army Hospital).
Holistic Home Birth client:
If you are a client of Holistic Home Birth, you simply need to let you midwife know your plans to encapsulate. No pick-up or delivery fee is charged!
This form may not be compatible with all phones or mobile devices. Please feel free to call if you have any trouble submitting your form. You are also welcome to take a "screen capture" of your completed form, amd email it to me at email@example.com.