Reserve your encapsulation.Please fill out the form below to reserve your encapsulation. We will then reach out to you for next steps. WE are excited to help you heal! Contact information Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### birth information Due Date * MM DD YYYY Birth Location: Name of Hospital or Birthing Facility * Doctor or Midwife Name * Encapsulation information I would like my capsules to be the following flavor(s): * Berry Bubblegum Caramel Mocha Grape Lime Orange Vegan I have the following allergies/sensitivities: I would like the following add-ons to my encapsulation: Placenta Print ($25) Umbilical Cord Keepsake ($25) If purchasing a placenta print, please choose color(s) for your print: blue green orange pink purple red teal yellow I would like mama afterglow encapsulation to post my encapsulation on social media, and tag me in it. yes, please! no, thank you. If yes, please add your social media handle(s) below. legal information I understand that THE ONLY reason my placenta would be unsafe to encapsulate is if I am HIV Positive or have AIDS. * I understand. I understand that a $50 non-refundable deposit is required to confirm my placenta encapsulation reservation. * i understand. Limitations and Disclaimer: I am not a licensed medical professional and I am not able to diagnose, treat or prescribe for any health condition. Services and fees are for the preparation and encapsulation of your placenta, not for the sale of the pills. No specific benefits or effects are promised. Benefits will vary from person to person. Many of the benefits are well supported by evidence based research; but none have been evaluated or approved by the FDA. (INITIAL BELOW) * Client Responsibility: It is your responsibility to notify me when you are in labor and again as soon as possible after the birth to make arrangements for transfer of your placenta to me. Improperly handled placentas are susceptible to spoilage and all placenta work is done at your own risk. I understand that the act of ingesting placenta in any form has not been tested, nor approved by the FDA, and I ingest this at my own risk. Furthermore, I release Mama afterglow Encapsulation (Arlett Murillo and associates) and its representatives from any liability. (INITIAL BELOW) * It is your responsibility to discuss the release of your placenta with your primary health care provider as well as the facility you will be birthing in. Your placenta may be kept at room temperature for 3-4 hours following your birth. After that, or as soon as possible, it should be placed on ice or in a refrigerator. (INITIAL BELOW) * Medical Contradictions: I certify that I have never been diagnosed with and am not now afflicted with any of the following diseases: ●AIDS ●HEPATITIS A ● HEPATITIS B ● HEPATITIS C ● HIV (INITIAL BELOW) * By entering your name below, you affirm all of this information to be correct and true: *