Consent To Release Placenta From A Hospital Or Birthing Center For Personal Use (Page 2 of 2) in pdf

Consent To Release Placenta From A Hospital Or Birthing Center For Personal Use Page 2

Consent to Release Placenta from a Hospital or Birthing Center for Personal Use

Mother’s name:

___________________________________________

Name of mother’s spouse:

___________________________________________

(if mother is incapacitated or deceased)

Hospital or birthing center at which the mother gave birth on _________________ date:

Facility name:

__________________________________________________

Address:

__________________________________________________

I, ________________________________________________, request and acknowledge the release of

the above named mother’s placenta from the above named healthcare facility. I understand and

acknowledge that:

• I have received educational material from the hospital or birthing center, provided by the Texas

Department of State Health Services, regarding infectious disease and other risks associated with

taking the placenta home;

• The above named hospital or birthing center is not responsible for the use, storage, or disposal of

the placenta after delivery to the mother;

• No test can completely ensure the absence of infectious diseases in the placenta, and I accept any

risk of infection to myself and others who handle this placenta; and

• I am taking the placenta for personal use only, and I cannot sell the placenta.

According to the Texas Health and Safety Code Chapter 172, the mother or mother’s spouse may not

have the placenta released to them under certain circumstances, including: evidence of the mother’s

infection with certain diseases and the need to perform pathological examination of the placenta

necessary according to a physician or healthcare facility.

Further detail regarding acceptable packaging, procedures, and policies to release the placenta are to be

determined by the hospital or birthing center named above.

Mother or spouse name (print):

_________________________________________________

Mother or spouse signature:

_________________________________________________

Date: __________________

Time:

__________________

Witness name (print):

_________________________________________________

Witness signature:

_________________________________________________

Date: __________________

Time:

__________________

Consent To Release Placenta From A Hospital Or Birthing Center For Personal Use Page 2