Elective Ultrasound WAIVER, ACKNOWLEDGEMENT & RELEASE OF LIABILITY AND HOLD HARMLESS

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Elective Ultrasound WAIVER, ACKNOWLEDGEMENT & RELEASE OF LIABILITY AND HOLD HARMLESS

*PLEASE READ CAREFULLY PRIOR TO CHECKING/DIGITALLY SIGNING*

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Email *

Name-First & Last *

Day of appointment *

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Time of appointment *

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Date of Birth *

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I acknowledge this ultrasound: (i) Is an ELECTIVE procedure that I have voluntarily requested; (ii) Is NOT intended to take the place of a medical diagnostic ultrasound or any other test or treatment that has been or may be recommended by your healthcare provider; (iii) Will not result in you obtaining or in Expecting Miracles, LLC, its owners, officers, staff and employees reporting any medical information; (iv) Is an out of pocket expense and will NOT be covered by any medical insurance. *

-ELECTIVE ULTRASOUND-

By checking here, I acknowledge, fully understand and agree to the above. Checking this box acts as your digital signature.

Required

I understand and acknowledge that standard prenatal care is essential to a healthy pregnancy. I acknowledge that: (i) I am under the care of a practicing physician/Obstetrician; (ii) Any and all concerns I may have regarding my pregnancy should be discussed by me with my physician/Obstetrician; (iii) I will in NO way seek medical advice or services of any kind or type from Expecting Miracles, LLC its owners, officers, staff and employees; (iv) I understand that it is not appropriate to ask staff of Expecting Miracles, LLC it's owners, staff and employees any questions regarding the health and well-being of my unborn child; and (v) I understand that in the event of absent fetal heart tones, my OB will be notified.

-PRENATAL CARE-

By checking here, I acknowledge, fully understand and agree to the above. Checking this box acts as your digital signature.

I acknowledge that is inherent risk in any activity involving a fetus and there are potential risks in this type of activity. I understand that no detrimental effects due to ultrasound have been found in over 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 Expecting Miracles, LLC, its owners, officers, staff and employees. *

-ASSUMPTION OF RISK-

By checking here, I acknowledge, fully understand and agree to the above. Checking this box acts as your digital signature.

Required

I am purchasing services and products from Expecting Miracles, LLC for the sole purposed of prenatal bonding. I agree that neither I, the father of my baby nor my baby have any recourse against Expecting Miracles, LLC, it's owners, staff and employees 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. I further agree to release and hold harmless Expecting Miracles, LLC, its owners, officers, staff and employees from any and all liability that may result from the services provided to me by Expecting Miracles, LLC. *

-NO PROFESSIONAL MEDICAL NEGLIGENCE CLAIMS-

By checking here, I acknowledge, fully understand and agree to the above. Checking this box acts as your digital signature.

Required

I hereby waive, release, acquit and forever discharge Expecting Miracles, LLC, its owners, officers, staff and employees 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, the father of my baby or my baby may have arising out of or in any way related to my visit to and the services provided by, Expecting Miracles, LLC. I agree that neither I, the father of my baby or my baby shall have any right whatsoever to file any lawsuit or institute any other actions or legal proceedings of any kind or type arising out of or in any way related to my visit to Expecting Miracles, LLC, its owners, officers, staff and employees. *

-WAIVER AND RELEASE OF CLAIMS-

By checking here, I acknowledge, fully understand and agree to the above. Checking this box acts as your digital signature.

Required

I acknowledge that every effort is made to capture good quality images of your baby, however we cannot guarantee the cooperation nor the position of the baby. Sometimes if the baby's position is face down, (i.e. towards your spin) it will be extremely difficult to see the baby's face. In this case, a one time complimentary abbreviated re-scan can be scheduled with in a 1-2 week window. Every baby scans differently, depending on the gestational age, position, amount of fluid, placental location and mother's body habitus. However, we promise to make every effort to obtain the best images. If we are unable to get a good image of your baby, we have still provided the service of the 3D/4D thus we will not provide a full refund if you are unhappy with the results. *

-PICTURE QUALITY-

By checking here, I acknowledge, fully understand and agree to the above. Checking this box acts as your digital signature.

Required

I acknowledge that every effort is made to VISUALIZE your baby's genitals for an accurate gender determination during your appointment, however we cannot guarantee the cooperation of the baby. If we are unable to tell at your appointment we will offer a one-time complimentary re-scan to be scheduled within 7 days. While we do our best to accurately predict your baby's gender there is NO way to be 100% without checking baby's chromosomes histologically by obtaining genetic information. However we promise to make every effort to obtain the best images and give you an accurate assessment of your baby's gender. If we are unable to get a good image of your baby, we have still provided the service of a 2D Sneak Peek ultrasound thus we will not provided a full refund if you are unhappy with the results. *

-GENDER DETERMINATION ACCURACY-

By checking here, I acknowledge, fully understand and agree to the above. Checking this box acts as your digital signature.

Required

I give Expecting Miracles, LLC permission to post or use any photos or recorded data for social media or advertisement purposes. I understand no names will be posted or used with the photos.

-PHOTO RELEASE-

By checking here, I acknowledge, fully understand and agree to the above. Checking this box acts as your digital signature.

By signing below, I consent to have elective ultrasound services performed by an Expecting Miracles, LLC staff member who has had comprehensive training to assure the best image quality. *

By checking here, I acknowledge, fully understand and agree to the above. Checking this box acts as your digital signature.

Required

I have carefully read this acknowledgement, release, waiver of liability and hold harmless and hereby acknowledge I fully understand and agree to its contents and that any question I may have had have been answered to my satisfaction. *

By checking here, I acknowledge, fully understand and agree to the above. Checking this box acts as your digital signature.

Required

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