Please read the consent below.
Elective 3D/4D Sonogram Consent Form
The undersigned acknowledges that she has willingly agreed to participate in an elective (not medically necessary) 3D/4D Sonogram performed by the faculty of Baby in Bloom 3D/4D Ultrasound LLC. The undersigned further acknowledges and agrees to the following conditions of participation in the Sonogram:
The Sonogram is NOT being performed for any type of diagnostic or medical treatment purpose.
The Sonogram is NOT being performed for the purpose of detecting any present or potential conditions, problems, or complications with the health or development of the undersigned or her unborn child.
An examination report will NOT be generated of the Sonogram for interpretation or diagnosis.
The Sonogram will NOT be supervised or interpreted by a licensed medical practitioner.
The records, results, and images of the Sonogram are NOT recorded nor maintained for purposes of patient diagnosis or treatment and are NOT “medical records”.
The undersigned will receive a keepsake fetal portrait/ on memory stick or photo drop and understands that Baby in Bloom 3D/4D Ultrasound LLC will NOT maintain copies of these images.
The quality of the images varies depending on the position and gestational age of the fetus as well as other factors such as placenta location, amount of amniotic fluid and expectant mother’s size and weight. No refunds will be given for any reason.
There are times when Gender is not well seen due to position or umbilical cord position. Baby in Bloom understands, sometimes baby can be challenging. We will reschedule for a return scan with in 7 days.
Because this is a non-diagnostic sonogram, the expectant mother must be under the care of an obstetrician, have medical clearance to have a 3D/4D ultrasound, and have had a prior diagnostic sonogram to screen for fetal anomalies prior to having this scan.
I understand that I am waiving my rights to access and confidentiality with respect to the performance and the results of the Sonogram and for all related duplication of that information, including, but not limited to, documents, recordings, videotape, digital information, and photographs (collectively the “Materials”). I further understand that Baby in Bloom 3D/4D Ultrasound LLC may disclose the Materials to faculty and students of Baby in Bloom 3D/4D Ultrasound LLC, to any agents or representatives of Baby in Bloom 3D/4D Ultrasound LLC, and to any licensed health care professional.
To the fullest extent permitted by law, the undersigned hereby releases and holds harmless, and agrees to indemnify, Baby in Bloom 3D/4D Ultrasound LLC, its officers, directors, shareholders, members, agents, employees, independent contractors, faculty and students (the Baby in Bloom 3D/4D Ultrasound LLC “Parties”), against all claims arising from (a) any personal injury, bodily injury or property damage whatsoever occurring in or at Baby in Bloom 3D/4D Ultrasound LLC or from the participation in the sonogram, (b) any personal injury resulting from the failure to disclose any health condition reasonably requested to be disclosed, orally or in writing, prior to participation in the Sonogram, or (c) the use or disclosure of the Materials, by the undersigned, the undersigned’s unborn child and their personal representatives, executors, heirs or assigns, except to the extent caused by the negligence or willful misconduct of Baby in Bloom 3D/4D Ultrasound LLC. I agree to defend, indemnify and hold harmless Baby in Bloom 3D/4D Ultrasound LLC and Baby in Bloom 3D/4D Ultrasound LLC Parties from any claim I should make in violation of this agreement.
We will have you sign a consent prior to the Ultrasound.