Book Now

Yes, Please add me to your PlacentaMom client calendar!

Thank you for choosing Tamara Morales of PlacentaMom.com to provide your placenta services. Please fill out the following client intake information and type your full name & the date at the bottom, as an electronic signature of acknowledgement of terms of service. I respect your right to privacy and assure you that all answers are held in strictest confidence.
***THIS FORM IS TO BE ADDED TO MY CLIENT CALENDAR ONLY*** For General questions or problems submitting this form please text me at 916-934-3333. Once I receive your book now form information I will email you my confirmation email, specific to your birthing location, that you MUST respond to in order to confirm receipt of. I try very hard to respond to all inquiries within 24 hours. So, if you do not receive a response from me within this time-frame please first check your spam/junk folder, and then send me a text to be sure I got your email/form submission. Sometimes, though rare, a form may fall into the weebly void and unfortunately will not be received. Thank you & I look forward to hearing from you.

* Indicates required field

Name (of who is having the baby) *

First

Last

Email (of who is having the baby) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Textable Phone Number (of who is having the baby) *

Yes, my textable # above is correct. Please review textable # above & confirm it has been inputted correctly. So many mistakenly enter their # incorrectly & then do not receive all needed information. Please enter YES below to confirm. *

Partner/Spouse's Name (if applicable) *

Partner/Spouse's Textable Phone Number (if applicable) * *

Expected Due Date (EDD) *

For Last Minute Clients Only *

Birthing Location *

Other Birthing Location - only if not included in list above *

Repeat PlacentaMom Client? *

If yes, when did you use PlacentaMom services in the past? *

Who referred you (if applicable) *

This is my... *

Multiples or Surrogate Baby? *

Comments &/or Questions *

I have asked Tamara Morales of PlacentaMom.com to prepare my placenta in capsule form for my own personal use. As a condition of this service, I make the following assertions:

I understand and agree that…

I am paying for the encapsulation preparation service only, which is not clinical, pharmaceutical, or intended to diagnose or treat any condition.
Payment is due upon Tamara Morales picking up the placenta for preparation. PlacentaMom's service fee is $200.
No refunds for services will be given.
My care provider and I will determine that my placenta is healthy and suitable for encapsulation.
Tamara Morales does not determine whether my placenta should be consumed and makes no guarantee of my personal results from the capsules.
My placenta does not contain any transmittable diseases such as Hepatitis-B, -C, or HIV/AIDS and that I have honestly disclosed my health history.
I will properly store the placenta according to instructions given that are appropriate for safe food preparation following my birth until pick up by Tamara Morales for preparation.
I will contact Tamara Morales following my birth according to instructions given.
While in the possession of Tamara Morales my placenta will be handled and encapsulated according to OSHA bloodborne pathogens universal safety precautions and Food Safety and Handling standards.
Tamara Morales views each placenta as a sacred connection between you and your child and will treat it accordingly.
I will not hold Tamara Morales responsible if my placenta is accidentally damaged during the encapsulation process.
My placenta will be properly stored, cleaned, steamed, dehydrated, and put into capsule form in Tamara Morales's sanitary and disinfected dedicated placenta only work space separate from her home kitchen/living environment (Tamara's Placenta Workshop).
Tamara Morales is not responsible or liable for any issues preventing or delaying provision of the services that are beyond her control (ex. car accident, detainment, placenta sent to pathology dept., holidays, US Postal Service delays, loss, or theft, etc).
Tamara Morales will communicate if any unforeseen delay in service occurs (ex. power outages, equipment failure, illness, medical emergency, family emergency, etc).
All finished packages are mailed back via US Postal Service Priority Mail.
Tamara Morales is not responsible or liable for any finished packages delayed, damaged, lost, or stolen once they are mailed back to clients via the US Postal Service. Time stamped mail receipt of mailing with US Postal Service Priority tracking information marks services rendered by Tamara Morales. Refunds will not be given for any packages marked delivered via US Postal Service tracking.
Due to US Postal Service sales counter hours of operation all finished packages are mailed out Monday-Friday. Tamara Morales will provide mailing updates, but it is expected that placentas picked up on Thursday may be mailed out either Friday or Monday and placentas picked up on Friday will mail out on Monday (Tuesday if Monday is a postal holiday).
In some instances photos of my placenta or placenta products may be taken for educational, promotional, or record keeping purposes. If used no identifying information will be shared under any circumstances. My consent is given for photos to be taken.
I authorize the release of my placenta to Tamara Morales and I authorize Tamara Morales to transport my placenta for preparation.
I give my authorization to have a spouse/partner, close family member, or friend fill out and sign on my behalf all forms needed by Tamara Morales upon the placenta being picked up for preparation.
Completing this form is for booking services only & I will be added to Tamara Morales's client calendar.
I understand that my home or birthing location may be outside of the standard area for pick up and an out of area service option may apply. If applicable, information will be provided before being added to Tamara Morales's client calendar. Birthing locations marked with an * are more likely to require an out of area service option, but not limited to.
I will read over all information provided by Tamara Morales upon being added to her client calendar & will confirm receipt of said information. I understand that an email response from the confirmation email sent is required to complete reservation of service.
If services are no longer needed I will contact Tamara Morales to be removed from her client calendar.
That my finished package will include my placenta capsules, cord keepsake (if umbilical cord was included in the packaged placenta), & an information card with all usage information.
I will follow suggested usage information included with my finished package and understand the capsules should not be taken during times of illness, such as the common cold, flu, or mastitis. I understand that taking the capsules may make these conditions worsen.
If I have any questions regarding any aspect of services I will contact Tamara Morales directly for more information/clarification.
Tamara Morales of PlacentaMom.com is not a pharmacy, pharmaceutical representative, holistic practitioner, herbalist, homeopath, or medical doctor. Reported benefits of placenta encapsulation are supported by client experience and the information provided has not been evaluated by the Food and Drug Administration.
Placenta Encapsulation, or placentophagy, is intended solely for ingestion by who has birthed the placenta(s) and not for family members, friends, or other individuals and is not guaranteed to produce specific results.
The services offered are not clinical, pharmaceutical, or intended to diagnose or treat any condition. Clients who choose to utilize the services take full responsibility of their own health and for researching and using the offered services. Tamara Morales makes no guarantee as to capsule efficacy, but does guarantee the highest quality of service.
I will speak to my medical care provider(s) regarding any questions about my health, safety, and well-being. I understand that placenta services are not meant to be a replacement for medical advice, medical care, or medicine. If I experience symptoms of postpartum depression, low milk supply, etc. I will call my care provider to discuss my symptoms and how to feel better, as well as treat any existing symptoms or potential conditions. I understand that while many clients have found placenta encapsulation to be a wonderful and amazing gift, I am still encouraged to seek appropriate assistance and medical care when necessary, as it is always okay to ask for help.
Tamara Morales will keep this document on file as a record for our agreement. No copies will be released to any third parties and all client information will be kept strictly confidential.
I release Tamara Morales from any and all liability for any effects I may experience after choosing to take the capsules.
I have read, understood, and agreed to the above procedures, information, and statements of policy.

Please type your legal first & last name, as your electronic legally binding signature, to show that you have read & agreed to all of the above information and that all of the above information submitted by you is true and accurate. *

Date Completed (Please use 00/00/0000 format for date) *

Submit

​​Yes, Please add me to your PlacentaMom client calendar!

Yes, Please add me to your PlacentaMom client calendar!