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Cincinnati & Dayton Placenta Encapsulation Registration

Placenta Encapsulation Form

* indicates required field

Client's Name
Client's Cell Phone
Spouse/Partner Name
Spouse/Partner Cell Phone
Home Address
Email Address
Planned Place of Birth
Caregivers Name
Name/Ages of Other Children
Any allergies you would like me to be aware of?
What method would you prefer for preparing your placenta?
Do you want to add tinctures?
Do you want to add salve?
Do you want some of your dehydrated placenta in the salve?
Do you want to add placenta art?
I understand that if my pickup/drop-off locations are more than 30 miles from your house, I will be charged an additional travel fee of $30

A $100 deposit is required upon registration. Please note that 4% is added to the deposit as it is processed through PayPal, to cover processing fees. The rest of payment will be due upon receiving the encapsulation.

* Deposit Deposit
$100 Deposit

The following is our Placenta Encapsulation Agreement that sets out the terms, scope and limits of the services we provide. I am excited to be walking with you on this journey!


I hereby acknowledge and agree that I understand the nature and potential risks involved and related to ingesting or otherwise using placenta products; that I hereby assume all risks, known and unknown, foreseeable and unforeseeable, in any way connected with ingesting or otherwise using placenta products; I accept full responsibility for any liability, injury, loss, damage or death in any way connected with ingesting or otherwise using placenta products for me and my family. I acknowledge that using the placenta products is at my sole risk. I understand and agree that ingesting placenta products is my own choice based on my personal, spiritual and cultural beliefs, and it is not intended to prevent or treat any physical or mental diseases, ailments or symptoms; I fully assume the full risk of doing so. I waive any and all rights to hold Stork Helpers LLC and/or its employees (hereafter “Placenta Encapsulator”) responsible for any undesired effect of consuming or using the products.

I understand and agree that there are no legal, regulatory or licensure specifically required for placenta encapsulation in my state. I understand and agree that the placenta will be handled by the Placenta Encapsulator according to OSHA and Stork Helpers LLC Food Safety and Handling standards, and will be prepared in a sanitary and disinfected work space.


I understand and agree that the information I receive from the Placenta Encapsulator in connection with the service(s) performed or otherwise is not intended or implied to be a substitute for professional, medical, nursing or nutritional advice, diagnosis or treatment. All content including text, graphics, images and information, communicated by or available through the Placenta Encapsulator is for general information purposes only. I agree and understand that the Placenta Encapsulator makes no representation and assumes no responsibility for the accuracy of information given. I understand that I am encouraged to confirm any information obtained from or through the Placenta Encapsulator with other sources, and review all information regarding any medical condition or treatment with my physician. I agree never to disregard professional medical advice or delay seeking medical treatment because of information I have been given by the Placenta Encapsulator.

I understand and agree that the Placenta Encapsulator is not practicing medicine, providing healthcare, psychiatric or psychological counseling nor nutritional therapy services. The Placenta Encapsulator will not and does not diagnose, prescribe, treat, prevent or cure, in any manner whatsoever, any disease, condition or other physical or mental ailment of the human body. I understand and agree that the Placenta Encapsulator is not acting in the capacity of a doctor, healthcare provider, licensed dietician or nutritionist, psychologist or other licensed or registered professional.

I understand and agree to maintain a relationship with my primary care physician, or specialist and to seek their professional advice regarding Placenta Encapsulation. I agree never to discontinue or change my current course of medical treatment due to the benefits derived from these services without first consulting my doctor.


I hereby release and hold harmless the Placenta Encapsulator from any and all liability or claims which may arise from placenta encapsulation services and/or the use of placenta products prepared by the Placenta Encapsulator, inclusive of, but not limited to, any injury or death resulting from an exposure to allergies, food borne illnesses, or choking. I and my successors, agents or assigns, hereby forever and unconditionally releases the Placenta Encapsulator, its owners, officers, employees, agents, successors in interest and insurers, heirs, executors, administrators, assigns, agents, trainers, placenta preservation certifying association, representatives, and all others acting on their behalf (hereinafter referred to as the “Released Parties”), from any and all claims, actions, damages to your person and/or property or that of your family, liabilities, injuries, losses, costs, and expenses, including, without limitation, attorney’s fees, in any way arising out of, or resulting from, my voluntary use of placental services and products including those caused by negligent act or omission of any of those mentioned or others acting on their behalf, arising out of or connected with services provided by me or the Released Parties. I further acknowledge that the Placenta Encapsulator is in no way liable for any injury resulting from my own conduct or behavior.


I acknowledge and agree that neither party shall be liable for any failure of or dealt in the performance of this agreement for the period that such failure or delay is beyond the reasonable control of a party, materially affects the performance of any of its obligations under this agreement, and could not reasonable have been foreseen or provided against.


This Agreement may not be modified without the prior written consent of Client and Placenta Encapsulator. The waiver by either party of a breach, right or obligation shall not constitute a waiver of any other or subsequent breach, right or obligation. If any provision of this Agreement is found to be invalid or unenforceable for any reason, the remainder of this Agreement shall remain in full force and effect. This Agreement sets forth the entire agreement between the parties and supersedes all prior proposals, agreements and representations between the parties, whether written or oral, regarding the subject matter herein. Neither party may assign this Agreement without the prior written consent of the other party. This Agreement shall be binding upon and shall benefit the parties and their respective successors and permitted assigns. Except as provided to the contrary herein, those provisions of the Agreement that by their nature and context are intended to survive the termination of this Agreement, shall survive any termination of this Agreement. This Agreement shall be construed and interpreted in accordance with the laws of the state in which the Placenta Encapsulator resides without reference to its conflict of law provisions, and with the same force and effect as if fully executed and performed therein. Each Party hereby consents to the exclusive personal jurisdiction of the State and Federal Courts where the Placenta Encapsulator resides, and acknowledges that venue is proper only in such courts.

Any dispute arising out of or relating to this Agreement, including without limitation, the validity, interpretation, performance, or breach thereof, shall be settled by arbitration in the jurisdiction where the Placenta Encapsulator resides, and shall be done so pursuant to the rules of the American Arbitration Association. Judgment upon any award rendered may be entered before an appropriate court in that state of venue.

If the terms of this Agreement are acceptable, please sign the acceptance below. By doing so, you acknowledge that: (1) you have received a copy of this letter agreement; (2) you have had an opportunity to discuss the contents with me and, if you desire, to have it reviewed by your attorney; and (3) you understand, accept and agree to abide by the terms hereof.

IN WITNESS WHEREOF, Client and Placenta Encapsulator agree to the terms and conditions set forth in and have duly executed this Client Commitment & Agreement effective as of the date of Placenta Encapsulator’s signature as set forth below.

Total: $0.00
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