By submitting this form, I certify that I have asked a Bloom Placenta Encapsulation Specialist, to prepare my placenta in capsule form for my own personal use. As a condition of this service, I make the following assertions

I agree that...

I am paying for the encapsulation and/or tincture service only. My placenta does not contain any transmittable diseases such as Hepatitis-B, -C or HIV/AIDS. My care provider and I have determined that my placenta is healthy and suitable for encapsulation. The placenta has been handled in a manner appropriate for safe food preparation since the birth.

I understand that...

Infection during labor or heavy meconium present during labor or delivery would be a contraindication for encapsulation. My BPES does not determine whether my placenta should be consumed and makes no guarantee of my personal results from the capsules.

It is my responsibility to notify my BPES when I go into labor and as soon as possible after the baby is born.

My BPES will strive to pick up my placenta within 24 hours of delivery. I understand that this may not always be possible and that I am responsible for making proper storage arrangements until she is available for pickup.

My BPES will strive to return the finished product to me within 72 hours of pick-up however, I understand this may not always be possible. No refund will be issued for delivery of the finished product beyond 72 hours of pick-up.

If we are unable to secure the release of our placenta or if the placenta is deemed unsuitable for encapsulation, my BPES will refund any payment made.

Client Responsibility

It is your responsibility to inform the hospital staff that you intend to retain your placenta. You should plan in advance for any requirements of your birthing facility for release or refrigeration of your placenta. Bloom recommends that you purchase a disposable Styrofoam cooler to safely store the placenta on ice for 24 hours.

It is my responsibility to notify my BPES as soon after delivery as possible so that they are able to prepare my placenta in a timely manner.


Fee for services is $200. A $50 deposit is required upon completion of this form to reserve our services.  An invoice will be created and is due upon delivery of the final product.  This includes placenta capsules and optional cord keepsake (when possible). Please note a $25 travel fee for pickup or delivery will be incurred for travel outside of Box Elder, Weber, Morgan, and Davis Counties.

Disclaimer: The act of ingesting placenta in any form has not been tested, nor approved by the FDA. The services offered by Bloom Birth LLC are not intended to diagnose or treat any condition. All claims of treatment on this site are from client experiences and not from medical testing.
Copyright © 2018 - Bloom Birth LLC
1825 W 4400 S, Roy, Utah 84067
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