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This Little Piggy Ultrasound consent form
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Name- First & Last *
Address *
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Email Address (your privacy is assured) *
Due Date *
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Name of OB provider *
How did you hear about This Little Piggy Ultrasound *
Instagram handle (We'd love to follow you!)
Prenatal Care: I acknowledge that I have been informed by The Little Piggy Ultrasounds that prenatal care is important to a healthy pregnancy. I understand that in no way is this elective ultrasound to be substituted for routine prenatal care. Concerns Should Be Referred to Physician: If I have any concerns regarding my pregnancy, I will contact my doctor. I will in no way rely upon This Little Piggy Ultrasounds or its services for medical advice. I understand that it is not appropriate to ask the staff of This Little Piggy Ultrasounds any questions regarding the health and well being of my unborn child. No Professional Negligence Claims: I am purchasing This Little Piggy Ultrasounds’ services and products for keepsake, non-medical purposes. I agree that I have no right to recourse against This Little Piggy Ultrasounds 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. This Little Piggy Ultrasounds 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 This Little Piggy Ultrasounds.Waiver and Release of Claims: I hereby waive, release, acquit and forever discharge This Little Piggy Ultrasounds 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 This Little Piggy Ultrasounds. I agree that I shall have no right to 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 This Little Piggy Ultrasounds. Photo Release: I give This Little Piggy Ultrasounds 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. I have notified my physician that I have chosen to obtain an elective 3D/4D fetal ultrasound from This Little Piggy Ultrasounds. I understand this has not been ordered by my physician. 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 other than medical purposes, without a physician’s prescription, is an unapproved use. I have been informed that This Little Piggy Ultrasounds, follows FDA recommendations for frequency (sound waves) and length of scan which has found no detrimental effects in 40 years of case studies. Further, the undersigned agrees and acknowledges that no guarantee can be made or has been made at the time of the imaging as to the picture or video quality and/or content of the imaging due to circumstances beyond the control of This Little Piggy Ultrasound, including, but not limited to: the position of the fetus(es), position of the placenta, mother's body habitus or position of the internal organs of the mother. If the technician deems beneficial, and you qualify by being in the recommended gestation for your session choice, the undersigned may be brought back for one rescan session at no charge within 7 days of initial appointment. If at that time the position of the fetus(es) impedes on the quality of images, all further rescan sessions are only $39.00 per session. Rescan sessions vary in length from 5 to 15 minutes. As we provide a service, not a product, refunds will not be granted for any circumstances listed above, or for circumstances out of our control. BY ACCEPTING THE TERMS OF SERVICE, I CERTIFY THAT I HAVE CAREFULLY READ AND UNDERSTAND THIS LIABILITY WAIVER AND RELEASE. *
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