CLIENT INFORMATION
NAME
STREET ADDRESS
CITY/ZIP
PHONE 1
Format: (000) 000-0000.
PHONE 2
Format: (000) 000-0000.
EMAIL
example@example.com
OBGYN/PRENATAL CARE PROVIDER
PRACTICE NAME/CITY
DOCTOR PHONE
Format: (000) 000-0000.
ESTIMATED DUE DATE
/
Month
/
Day
Year
DO YOU HAVE ANY CONCERNS WITH THIS PREGNANCY?
ANY PRIOR ULTRASOUNDS WITH THIS PREGNANCY?
Do you want to know the gender?
WOULD YOU LIKE TO PURCHASE ANY OF THE FOLLOWING?
Heartbeat animal (animal selection will vary and chosen at appointment) - $30 $25 with Package C
Estimated fetal weight (done after 15 weeks) - $15 **included in Package C
Gender reveal smoke cannon - $15 (appropriate cannon will be given at end of session)
Additional B&W prints - $2 per print
PEEK-A-BOO TO YOU!
WAIVER AND RELEASE FORM
PRENATAL CARE
I am currently under the care of a physician or healthcare provider in regards to this pregnancy and their contact information has been disclosed. I acknowledge that I have been informed by Peek-a-Boo To You! that prenatal care is important and my Doctor has no objections to this elective ultrasound.
PREGNANCY CONCERNS
In the absence of fetal heart tones, I understand that I will be told immediately and can choose to continue or end my session. Also, my OB provider will be notified during their regularly scheduled business hours. This ultrasound is an elective, non-medical procedure that I have voluntarily requested.
NO PROFESSIONAL NEGLIGENCE CLAIMS
This session is not intended to take the place of any test or treatment that has been recommended by my healthcare provider, including a diagnostic ultrasound to confirm fetal well-being. While the Technologist performing the ultrasound is a trained professional qualified to perform such ultrasound services, this session is intended solely for entertainment purposes and not intended to provide any diagnostic services or give any medical information or advice. If I have any concerns regarding my baby, I will contact my Doctor. I will not rely upon Peek-a-Boo To You! for medical advice.
ASSUMPTION OF RISK
I acknowledge that there is inherent risk in any activity involving a fetus. I understand that Peek-a-Boo To You! follows FDA standards on length of scan and frequency of sound waves although no detrimental effects have been proven in 40 years of research. I hereby voluntarily assume in all risk of harm or injury to me or my baby resulting from the services provided by Peek-a-Boo To You!.
PICTURE QUALITY
I acknowledge that maternal body type, fetal age/size, fetal position, placenta location and the amount of fluid surrounding the baby could limit the image quality. Every attempt will be made to get the best images possible and determine the gender but even if I am unsatisfied with the image quality. service was still provided by Peek-a-Boo To You! and a refund will not be given since the elements were out of everyone's control.
WAIVER AND RELEASE OF CLAIM
I hereby waive, release, acquit and forever discharge Peek-a-Boo To You! from any and all claims, expenses, demands, costs, cause of action, and other actions and liabilities whatsoever, whether known or unknown, whether in law or equity, that me, my affiliates or my baby may have arising out of or in any way related to my session. I agree that I shall have no right 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 the services rendered from Peek-a-Boo To You! including error in gender determination.
PHOTO RELEASE
I give my permission for Peek-a-Boo To You! to use any photos or recorded data for advertisement purposes. I understand that none of my personal information will be disclosed.
I HAVE READ AND UNDERSTAND ALL OF THE ABOVE. I AGREE TO ALL OF THE
Signature
Date
/
Month
/
Day
Year
Date
Technologist
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