Encapsulation Agreement

Placenta Encapsulation Agreement (NP)

First Name

Last Name

Cell Phone

Alternate Phone

Street Address

City

State

Postal / Zip code

Note: $20 mileage fee applies to clients to Kyle, Dripping Springs, Manor, Jonestown, Georgetown, Hutto, Leander, Lago Vista, Lakeway, Elgin, Spicewood, Bee Cave, Marble Falls and other towns not listed that are 15+ miles from Central Austin. Additional fee may apply for 40+ miles from Central Austin.

Estimated Due Date/Baby's Birthday

Name of Hospital/Birth Center/Home

Name of Doctor/Midwife

Placenta Encapsulation Fee (note a 4% processing fee is included in the price)

Single Placenta - $234

Twins Placenta - $312

I agree to the terms and conditonsView terms and conditions

Pickup Agreement

I understand that my placenta will be picked up during daytime hours (8am-8pm) and I will not call/text the doula line overnight. I understand that I can notify ATX Doulas overnight by email only at placentas@atxdoulas.com

Your Signature

Thank you for signing up for placenta encapsulation!