Waiver and Release Form

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Client Information & Waiver

 

NAME: ______________________________________________________________

HOME ADDRESS: _____________________________________________________

CITY, ZIP: ____________________________________________________________

PHONE: (HOME) _________________________ (WORK) _____________________

EMAIL:_______________________________________________________________

DOCTOR NAME: ______________________________________________________

DOCTOR ADDRESS: ___________________________________________________

DOCTOR PHONE: _______________________________ DUE DATE: ___________

HOW DID YOU HEAR ABOUT US: _______________________________________

Prenatal Care: I acknowledge that I have been informed by Angelic Baby 3-D Ultrasound that prenatal care is important to a healthy pregnancy. I am currently receiving prenatal care and my doctor has been informed and has no objections to my attending this sonography session.

 

Concerns Should Be Referred to Physician: I have also been informed by Angelic Baby 3-D Ultrasound that use of Angelic Baby 3-D Ultrasound services cannot substitute for care of a physician. If I have any concerns regarding my pregnancy, I will contact my doctor. I will in no way rely upon Angelic Baby 3-D Ultrasound or its services for medical advice.

 

No Professional Negligence Claims: I am purchasing Angelic Baby 3-D Ultrasound services and products for keepsake, non-medical purposes. I agree that I have no right to recourse against Angelic Baby 3-D Ultrasound in any medical malpractice, professional negligence, or any medical related claim arising out of or in any way related to my pregnancy or the birth of my child. This includes any claim for error in gender determination.

 

Assumption of Risks: I acknowledge that there is inherent risk in any activity involving a fetus and there are potential risks in this type of activity. I understand Angelic Baby 3-D Ultrasound follows FDA recommendations for length of scan and frequency of ultrasound sound waves, and that no detrimental effects have been found in 40 years of studies. I hereby voluntarily assume all risk of harm or injury to me or my baby resulting from the services provided by Angelic Baby 3-D Ultrasound.

 

Waiver and Release of Claims: I hereby waive, release, acquit and forever discharge Angelic Baby 3-D Ultrasound from any and all claims, expenses, demands, costs, causes of action, and other actions and liabilities, of any nature whatsoever, whether known or unknown, whether in law or equity, that I or my baby may have arising out of or in any way related to my visit to Angelic Baby 3-D Ultrasound. I agree that I shall have no right whatsoever to file any lawsuit or institute any other action or legal proceedings of any type arising out of or in any way related to my visit to Angelic Baby 3-D Ultrasound.

 

Photo Release: I give Angelic Baby 3-D Ultrasound permission to post or use any photos or recorded data for advertisement purposes. I understand no names will be posted or used with the photos.

 

Picture Quality: I understand picture quality is dependent on many factors. I understand that Angelic Baby 3-D Ultrasound is not always able to obtain pictures of every baby. I understand no refunds are available if unable to obtain pictures or gender.

 

I have notified my physician that I have chosen to obtain an elective 3-D fetal ultrasound­ from Angelic Baby 3-D Ultrasound & I understand my physician has not ordered this. I understand that this ultrasound is not to be used to replace physician care. I have been informed that the federal Food and Drug Administration has determined that the use of medical ultrasound equipment for reasons other than medical purposes, without a physician’s prescription, is an unapproved use. I have been informed that Angelic Baby 3-D Ultrasound follows FDA recommendations for frequency (sound waves) and length of scan which has found no detrimental effects in 40 years of case studies.

 

I have read and understand all of the above. I agree to all of the above.

 

Signature: __________________________________________ Date: ______________