Starting the Encapsulation Process

We are honored that we will be working with you! We ask you to fill out this information so we can learn a bit more about you and your wishes with your placenta.

Please mail any necessary documents to: 1289 Fordham Blvd, Suite 106, Chapel Hill, NC 27514

Contact Emily at or 919/480.1423 if you have any further questions.


If not submitted already, please sign and return your contract at your earliest convenience. 


Payments can be mailed online, via PayPalphone, or by mailing a check with your contract.

Order Form

Personal Information
Name *
Address *
Phone *
Partner Information
Partner's Name
Partner's Name
Partner's Phone Number
Partner's Phone Number
Pregnancy Information
Estimated Date of Delivery *
Estimated Date of Delivery
Placenta Preferences
Requested Products *
Placenta Print *
We can either use the natural blood that is on the placenta to make the print or use food safe dyes to provide some color. Please specify what you prefer:
As a complimentary service, we can dehydrate your baby's umbilical cord to provide a wonderful keepsake. Please specify if you would like the cord as a circle, a specific letter, a specific word (if long enough), or another shape. If you are not interested in a cord keepsake please type "no".
We believe the safest form of placenta encapsulation occurs when it is inside of the client's home to ensure there is no confusion regarding whose placenta you are consuming. We do not bring placentas into our home for storage or process. Do you consent to having us bring all the necessary tools and products to encapsulate in your home?
It is recommended that you tell your medical provider prior to delivery that you would like to encapsulate your placenta as well as include in your birth plan. Has your doctor or midwife given approval for your placenta to be encapsulated by Carolina Birth and Wellness?
Please list any medications that you are taking. We will let you know if there are any medications you are taking are contraindicated for placenta encapsulation.
Please confirm that there are no blood borne illness that are present in my blood work testing. This specifically includes: HIV, Hepatitis, and STDs. Note: Encapsulation is safe for those that are GBS+.
Please list any complications with your pregnancy. Most pregnancy complications are not a factor in consuming your placenta, but it is important for us to know prior to beginning your placenta.
Contract and Consent *
We require that you sign a contract prior to Carolina Birth and Wellness encapsulating your placenta. Please indicate one of the following regarding your contract:
Payment Information *
We do not require a deposit, but do require that the service be paid in full prior to the start of the encapsulation process. This service is nonrefundable unless there is a medical reason why your placenta cannot be encapsulated. Should that occur, you will be refunded the full amount.