Ultrasound Registration Form

Package*

Today's Date*

First Name*

Last Name*

Email Address*

example@example.com

Your date of Birth*

Must be the the Date of Birth of the Mother-To-Be

First day of last period:*

Date

Spouse/Partner's Name*

Address*

City*

State*

Zip*

Contact Phone Number*

Is this a mobile phone number?*

Expected Due Date*

Date

How many weeks are you?*

Physician Name*

Physician Phone*

Physician Address*

Any complications during pregnancy?*

YesNo

If yes, please explain

When was your last ultrasound?

How did you hear about Perfect Gift?*

I would like to receive the email/text newsletter with Specials and Class Schedules*

YesNo

I verify the accuracy of the information above. I authorize Perfect Gift to disclose medical information to my healthcare provider if necessary. I understand that I am financially responsible for charges related to this ultrasound.

NO PHOTOGRAPHY OR VIDEO RECORDING IS ALLOWED IN THE ULTRASOUND SCAN ROOM, BY YOU OR ANYONE IN YOUR PARTY.

If anyone in your party is asked more than once to stop taking pictures or filming, your party will be asked to leave, and you will not receive a refund. Thank you very much for respecting our policy!

Patient Signature*

Today's Date*

Date

Notes (Office Use Only)

WAIVER OF LIABILITY: Perfect Gift understands the importance of proper medical care for both expectant mothers and fetus. Therefore, to provide our patients with an appropriate, meaningful ultrasound screening, Perfect Gift requires that you:

1. Certify that you are under the care of a physician or other health care provider, and that you are not obtaining this ultrasound as a replacement for, or in lieu of, standard prenatal medical care.

2. Notify your current physician or health care provider regarding the ultrasound you receive from Perfect Gift as a further condition to receiving limited diagnostic screening ultrasound services from Perfect Gift, you hereby acknowledge, understand, and agree to the following statements:

A. You understand that the quality of this ultrasound and the images depends upon many factors including maternal body habitus, developmental stage, and fetal position, and for those reasons we cannot guarantee the quality.

B. You understand that since Perfect Gift performs a limited medical diagnostic study with each ultrasound, and that since this ultrasound is not performed solely for the images you will receive as a byproduct of this limited diagnostic study, refunds are not available for any

C. This ultrasound is an elective procedure that I have voluntarily requested and is not intended to take the place of a diagnostic ultrasound or any other test or treatment that has been or may be recommended by my healthcare provider.

D. The technologist who performs this ultrasound while qualified to provide such ultrasound services, is not qualified to interpret, diagnose medial conditions from, or otherwise offer medical conclusions regarding the images produced.

E. You understand that you are responsible for contacting your own healthcare provider if you have any questions concerning this ultrasound or any other aspect of your pregnancy.

As evidenced by your signature below, you understand that factors beyond the control of Perfect Gift may also affect the ability to accurately determine the gender of the fetus, and that Perfect Gift can provide no warranty or guarantee as to the accuracy of any such determination. In consideration of the services rendered, you agree to release Perfect Gift, ultrasound technologists, owners, and employees from any and all claims or causes of action for injury. harm, damage or other liability which results from, or are alleged to have resulted from. this ultrasound, including but not limited to, the failure of Perfect Gift to accurately determine fetal

gender or other characteristics, and any damages or injuries resulting from, or alleged to result

from ultrasound which are not now not known to occur.

PERFECT GIFT RETURN POLICY: At Perfect Gift we strive to obtain the highest quality images. The quality of your pictures will depend on maternal anatomy. position of the baby,

body tissue percentage and amount of amniotic fluid, all which are beyond our control. We also have the highest quality technology along with trained and experienced Ultrasound Techs. If for any reason you are not happy with the images, please tell the Technician within the first FIVE

MINUTES of your session and she will stop and schedule you to come back. Our return policy requires that you come back within ONE WEEK of your original appointment. We do our absolute best to determine gender and it will be no-cost for you to return until our sonographer

gives you a positive gender indication.

FIRST TRIMESTER ULTRASOUND SCAN: The first trimester ultrasound is performed

between the gestational age of 5 weeks to 13 weeks. If you are earlier than 10 weeks, we may be unable to hear a heartbeat due to baby's development. This ultrasound is an elective procedure that I have voluntarily requested and is not intended to take the place of a diagnostic ultrasound or any other test or treatment that has been recommended by my healthcare provider. This ultrasound is for pregnancy confirmation and measurements for an estimated due date. The technologist is not qualified to interpret, diagnose medical conditions from or otherwise offer medical conclusions regarding the images produced. You understand that you are responsible for contacting your own healthcare provider for any questions regarding your pregnancy. You

understand that THE FIRST TRIMESTER ULTRASOUND DOES NOT FALL UNDER OUR

PERMISSION TO USE 3D PICTURES FOR MEDIA PURPOSES: Perfect Gift would like

to use the 3d Ultrasound pictures that we have on file for print ads or other media marketing. By booking any appointment with Perfect Gift. I authorize Perfect Gift to use pictures from my 3d/4d ultrasound for media purposes only.

CANCELATION POLICY: To cancel your appointment with Perfect Gift and receive a FULL

refund you must cancel within seventy-two (72) hours. Appointment cancelations within 48 hours will result in a seventy-five percent (75%) refund. Appointment cancelations without explanation within 24 hours will result in no (0%) refund.

"I have carefully read this document and by affixing my signature, I acknowledge that I fully

understand and agree to its contents:

Today's Date*

Date

"I have carefully read this document and by affixing my signature, I acknowledge that I fully understand and agree to its contents

Signature