2775 US-22 Suite 6 Maineville, OH •513-916-2229 • BlushingBaby4D.com

Blushing Baby 3D/4D Ultrasound LLC offers elective 2D/3D/4D/HD prenatal ultrasound for an entertainment keepsake and to provide a positive bonding experience for expectant mothers and their family and unborn baby in utero.  This entertainment ultrasound session will not provide any assumptions, diagnosis, or medical input of any kind and is not intended to take the place of a diagnostic ultrasound or any other medical procedure(s) recommended by your physician or health care provider.  I acknowledge the following:

As a condition of receiving an entertainment ultrasound from Blushing Baby 3D/4D Imaging, I,

hereby acknowledge, understand, and agree to the following statements:

•I am under the care of a physician or health care provider for the medical diagnosis, input, and recommendations relating to my pregnancy.

•I certify I am obtaining this 2D/3D/4D/HD ultrasound for entertainment only and I am not obtaining this ultrasound as a replacement for, or in lieu of, standard medical care.

•I have undergone a medical diagnostic ultrasound prescribed by my health care provider in regard to this pregnancy.  My health care provider ultimately will confirm my due date, screen for fetal abnormalities, and/or any abnormalities related to my pregnancy.

•This ultrasound is an elective, non-medical procedure that I have voluntarily requested.

•The technician performing the ultrasound is not a doctor or nurse and cannot interpret diagnostic medical conditions, or otherwise offer medical conclusions regarding the images.  I understand that the obtained images will not be reviewed by a radiologist or physician.  I agree that I have no right of recourse against Blushing Baby 3D/4D Imaging or my physician for any medical malpractice, professional negligence or medically related claims arising out of the use of this keepsake service.

•I understand that I am responsible for contacting my health care provider if any questionsarise concerning any issues relating to this ultrasound session or any aspect of my pregnancy.

•I give Blushing Baby 3D/4D Imaging permission to post and/or use any media in the form of still images or moving images for advertising purposes. I understand no names will be posted or released in association with these images or videos.

•I realize and understand the quality of my ultrasound images depends upon many factors including body habitus, developmental stage, fetal position, and adequate fluid.  I understand Blushing Baby 3D/4D Imaging does not guarantee the quality of the images or the ability to visualize any characteristics of the fetus such as gender and all images are not stored by Blushing Baby 3D/4D Imaging.  I further understand that factors beyond Blushing Baby 3D/4D Imaging’s control may also affect the ability to accurately determine the gender of the fetus, and that there is no warranty or guarantee as to the accuracy of any such determination.  I further understand that while ultrasound is believed to have no harmful or adverse effects on the mother or the fetus, further research or other information may disclose harmful or adverse effects that are presently unknown.

•In consideration of the services rendered, I agree to release and hold harmless Blushing Baby 3D/4D Imaging and its agents and employees (all referred to as the “released parties”), from any and all claims or causes of action for injury, harm, loss, damage, or other liability, whether caused by the negligence of the released parties or otherwise that result from or are alleged to have resulted from, this ultrasound.  In addition, I agree to release and hold harmless the released parties from any and all claims or causes of action for injury, harm, loss, damage, or other liability which results from, or are alleged to result from, the failure of the released parties to accurately determine fetal gender or any other characteristics of the fetus.  I will indemnify Blushing Baby 3D/4D Imaging with respect to any complaint and will agree to arbitration in the state of Ohio if any disagreements occur.

I have carefully read and understand this release and waiver of liability and hereby acknowledge I fully understand and agree to its contents.

 

I authorize Blushing Baby 3D/4D Ultrasound LLC the use and disclosure of my ultrasound images of my unborn baby in utero and to publish those ultrasound images for any lawful purpose, including, but not limited to, their website, social media accounts, and promotional materials, either digital or in print, in perpetuity. I hereby release to Blushing Baby 3D/4D Ultrasound LLC all rights to exhibit all images and videos in print and electronic form publicly or privately and to market copies. I understand that information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations. I waive any rights, claims or interest I may have to control the use of my identity or likeness in the images or videos of my ultrasound imaging session. I give Blushing Baby 3D/4D Ultrasound LLC permission to send copies of my unborn baby in utero ultrasound images and videos via electronic mail to the provided email listed below.

By signing and dating this document I authorize Blushing Baby 3D/4D Ultrasound LLC to edit, electronically send my elective ultrasound images of my unborn baby in utero.

Thank you for your continued trust in our studio. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus,” at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our studio and continue to do so. Despite our careful attention to sterilization, and disinfection there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant.  Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the client, guests and sonographer and sometimes other clients at all times.

 

Although exposure is unlikely, do you accept the risk and consent to have your elective ultrasound?