Bellissimo Birth Services
Placenta and Client Health Information Release
Name:
Address:
Phone:
Mother’s Birthday:
Due Date/Date of Birth:
Care Provider:
Birth Location:
I, ____________________ here by authorize ___________________ (care provider and/or employees) to release
my health information pertaining to placenta encapsulation to the following person(s):
Bonnie Baker
1120 Webb Lane
Kaysville, Ut 84037
801.979.9325
Care provider must complete section below
HIV/AIDS  Pos  Neg  Not tested
Hepatitis B/C:  Pos  Neg  Not tested (if positive please specify which:  B  C)
Gonorrhea:  Pos  Neg  Not tested
Syphilis:  Pos  Neg  Not tested
Chlamydia:  Pos  Neg  Not tested
Other blood borne diseases or STDs that should be noted: ____________________________________________
____________________________________________________________________________________________
Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human
papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma
venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.
______________________________________________________________________________
I hereby certify that the information provided above is true and correct.
Signature :_____________________________________( care provider) ________date
Signature :_____________________________________( client) ________date
For client purposes only:
Please read and sign that you understand the basic health concerns pertaining to placenta encapsulation.
There are amazing benefits to placenta encapsulation, however there are times when it is not advisable to
encapsulate and consume your placenta. The situations below would be reasons placenta cannot be consumed.
Is the client HIV positive? IF SO, for the safety of the client, myself, and others I cannot encapsulate the placenta.
Such placentas should not be consumed.
Does the client have Hepatitis B or C? IF SO, for the safety of the client, myself, and others I cannot encapsulate
the placenta. Such placentas should not be consumed.
Has the client been treated for any Sexually Transmitted Diseases or Infections during the past 12 months? IF SO,
for the safety of the client, myself, and others I cannot encapsulate the placenta. Such placentas should not be
consumed.
**In the event that the client develops an infection in her uterus before or during birth her placenta cannot be
encapsulated.
**Symptoms of infection in the uterus would include a fever during labor or flu like symptoms prior to labor
beginning.
**Please be aware that it is common for an epidural to cause a fever as well, so in the event of a fever, please speak
with your care provider to determine the cause of the fever.
**IF it is determined that it is not infection, we may proceed with encapsulation. However if the placenta is taken to
pathology we cannot encapsulate.
**IF it is determined that infection is the cause of the fever, for the safety of the client, myself, and others I cannot
encapsulate the placenta. Such placentas should not be consumed.
Any fees obtained prior to birth will be refunded.
Signature: ___________________________________________________ date______________
Signature: ___________________________________________________ date______________