Please submit this form, or your appointment will be CANCELED.
Only the client that is being seen is to fully complete & submit this form on her own PRIOR to arriving at View A Miracle for her ultrasound session.
Client's First Name
*
Full First Name
Client's Last Name
*
Full Last Name
DOB
*
/
Month
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Day
Year
Your Date of Birth (Birthday)
Email Address
*
example@example.com
Phone Number
*
Cell Phone #
Mailing Zip Code
*
Your 5 digit Zip Code
Have you been to View A Miracle before?
*
YES
NO
If YES
*
This pregnancy
Prior pregnancy
LMP (1st Day of Last Menstrual Cycle)
*
/
Month
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Day
Year
Estimate if necessary
DUE DATE
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Month
/
Day
Year
If Known
How many weeks pregnant are you?
If Known
Have you had an ultrasound with THIS pregnancy?
*
YES
NO
Do you know the gender of the baby?
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YES
NO
Do you want to find out the baby's gender to be revealed in the room during your scan?
YES
NO
How would you like to find out baby’s gender during your appointment?
Written on the screen during ultrasound
Put a reveal card in an envelope to open later
Verbally
Purchase an additional gender reveal item in our shop (+the cost of the item you pick)
Other
I already know my unborn baby's gender is
GIRL
BOY
Do you want to find out/confirm your baby's gender today? [Must be 12+ weeks pregnant]
YES
NO
If having a DNA Blood Test ($200), what is the email address you want your results sent to?
example@example.com
OB/GYN, Clinic or Midwife Name
If Known
Doctor's Phone Number
If Known
Do you need a Medical Report (extra fee) added to your 2D Ultrasound to bring to your Doctor, Midwife or Doula? If not, you can not add this option on later.
*
YES
NO
Client's Signature
*
Please check for any additional add-ons BEFORE the sonogram begins.
$0 *Newest Offer* East Brunswick Location Only- Complimentary Mini Facial by our licenced aesthetician at the conclusion of your ultrasound (if time allows). No additional charge. Note- adults only are permitted into the spa room.
$5 Five Black & White Printed Thermal Songram Images
$15 Weight/Size of Baby
$15 Four Printed Colored Pictures [3D or 5D Only- Not offered with any 2D package]
$25 Report added to the Pregnancy Confirmation scan (not offered on any other package)
$35(SM) or $45(LG) Stuffed Animal of your choice with Baby's Heartbeat Recording
$60 Medical Report [2D Only- Not offered with any 3D or 5D package]
How did you hear about us?
*
Friend
Family
Google
Facebook
Doctor's Office
Previous Visit
Midwife
Other
I understand that if I am unhappy with the ultrasound images of my baby that the sonographer is obtaining, I will say so within the first two minutes of the session. I will then be offered to reschedule my appointment at a later date or simply choose not to have this elective service being provided. If I decide to continue the session, I will be charged the full amount of the package. Once I leave the office with my text images and/or USB and then later decided that I'm not satisfied, the charge will not be removed nor a re-scan offered to me. [Please note that the highly qualified registered sonographer will make every attempt to get the best possible images of your baby in utero. Our services are guaranteed to satisfy you or you can request your money back, minus the $75 sitting fee. This offer is valid prior to you leaving the studio on all services. No exceptions.]
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Today's Date
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Month
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Day
Year
Date
Submit
Should be Empty: