August 4, 2018



Palm Beach Ultrasound/3D Baby Bump understands the importance of proper prenatal medical care for both the expectant mother and the fetus. Therefore, in order to provide our patients with an appropriate, meaningful ultrasound screening, Palm Beach Ultrasound/3D Baby Bump requires that you: (i) certify that you are under the care of a physician or other health care provider, and that you are not obtaining this ultrasound as a replacement for, or in lieu of, standard prenatal medical care; and (ii) notify your current physician or health care provider regarding the ultrasound you receive from Palm Beach Ultrasound/3D Baby Bump. We request that you present to Palm Beach Ultrasound/3D Baby Bump an acknowledgement of receipt of this notice, signed by your physician or health provider, prior to performance of the ultrasound. In the event you are unable to notify your physician or health provider prior to performance of the ultrasound, you assume sole responsibility for notifying him or her as soon as practical following performance of the ultrasound. As a further condition to receiving ultrasound services from 3D Baby Bump, you hereby acknowledge, understand and agree to the following statements: – This ultrasound: (i) is an elective procedure that I have voluntarily requested, and (ii) is not intended to take the place of any care or other test or treatment that has been or may be recommended by your healthcare provider. – Because of its elective nature, this ultrasound may not be covered by insurance. Therefore, advance payment is required. It is your responsibility to determine and how your ultrasound may be covered or reimbursed by your insurance provider. – The technician who performs this ultrasound, while qualified to provide such ultrasound services, is not a doctor, nurse or healthcare provider, and cannot interpret, diagnose medical conditions from, or otherwise offer medical conclusions regarding the images produced. – As used by 3D Baby Bump, this ultrasound is intended to provide enhanced images for the purpose of viewing fetal movement in utero. The technician will make no attempt to guarantee a medically inclusive ultrasound or fetal well being. – You understand that you are responsible for contacting your own healthcare provider if you have any questions concerning this ultrasound or any other aspect of your pregnancy. – You understand that the quality of the ultrasound depends upon many factors including; body tissue content, developmental stage and fetal position. You understand that Palm Beach Ultrasound/3D Baby Bump does not guarantee the quality of the videotape or the ability to visualize any characteristics of the fetus. As evidenced by your signature below, you understand that factors beyond our control may also affect the ability to accurately reveal abnormalities of the fetus, and that Palm Beach Ultrasound/3D Baby Bump can provide no warranty or guaranty as to the accuracy of any such. You further understand that while ultrasound is believed to have no harmful effect on the mother or the fetus, future research or other information may disclose harmful or adverse effects that are presently unknown. IN CONSIDERATION OF THE SERVICES RENDERED, YOU AGREE TO RELEASE PALM BEACH ULTRASOUND/3D BABY BUMP, ITS AGENTS, AFFILIATES, DIRECTORS, AND EMPLOYEES FROM ANY AND ALL CLAIMS OR CAUSES OF ACTIONS FOR INJURY, HARM, DAMAGE OR OTHER LIABILITY WHICH RESULTS FROM, OR ARE ALLEGED TO HAVE RESULTED FROM, THIS ULTRASOUND, INCLUDING, BUT NOT LIMITED TO, THE FAILURE OF Palm Beach Ultrasound/3D Baby Bump TO ACCURATELY REVEAL ABNORMALITIES OR OTHER CHARACTERISTICS, AND ANY DAMAGES OR INJURIES RESULTING FROM ULTRASOUND WHICH ARE NOT NOW KNOWN TO OCCUR. ”I have carefully read this document and by signing at the bottom, acknowledge that I fully understand and agree to its contents.”