grant permission to SNEAK PEEK ULTRASOUND (AKA THE WOMB, LLC), a Florida limited liability company (“Premier”) to perform an elective 3D/4D sonogram.
Ultrasounds for fetal portraits are not medically necessary and are not covered by any health insurance plan or flexible spending account. The full charge of your appointment will be paid prior to the exam.
I understand that this 3D/4D sonogram is elective in nature and is for entertainment purposes only. I understand that SNEAK PEEK ULTRASOUND cannot guarantee the accuracy of the 3D/4D images due to the unpredictable nature of my baby. Additionally, I understand that the images of my baby are not true predictions of how my child will appear after birth. Furthermore, I understand that there is a chance that during my visit my baby may not be optimally positioned (i.e. face down to my spine). I understand that SNEAK PEEK ULTRASOUND will try to accommodate me to the best of its ability and may ask me to return at a different time/day in such circumstances. I understand that all patients scan differently depending on gestational age, position, amount of amniotic fluid, placenta location and maternal weight, and my 3D/4D image may not be similar to those I have seen elsewhere.
If any illness, injury, or accident occurs which, in the sole judgment of the staff of SNEAK PEEK ULTRASOUND, requires immediate medical attention, I give consent to terminate the 3D/4D sonogram, and I understand that I will be referred to my acting OB/GYN provider.
For the sole consideration of SNEAK PEEK ULTRASOUND performing an elective 3D/4D sonogram, I hereby assume all risks of personal injury to myself and my baby in any way associated with the 3D/4D sonogram. Three (3) and four (4) dimensional ultrasounds to obtain keepsake fetal portraits is an elective, not a medically necessary procedure. The US Food and Drug Administration and the American Institute of Ultrasound in Medicine (AIUM) are opposed to the use of medical technology for entertainment. According to the US Food and Drug Administration (FDA) there are no known bio-effects on the fetus. However, future research may disclose harmful or adverse effects that are presently unknown.
I hereby agree that SNEAK PEEK ULTRASOUND, its members individually and its officers, agents and employees shall not be liable for any injuries or any damage to me or my baby, or be subject to any claim, demand, injury or damages, whatsoever, including without limitation, those damages from acts of passive or active negligence on the part of SNEAK PEEK ULTRASOUND, its members individually and its officers, agents and employees. I expressly acknowledge that SNEAK PEEK ULTRASOUND will not review the 3D/4D sonogram for any purpose and that it is not a diagnostic evaluation, nor is it intended to be diagnostic. I hereby agree to expressly forever release and discharge SNEAK PEEK ULTRASOUND, its members individually and its officers, agents and employees from all such claims, demands, injuries, damages, actions or causes of action. Further, I covenant not to sue SNEAK PEEK ULTRASOUND, its members individually and its officers, agents and employees. I acknowledge that I have carefully read this paragraph and fully understand that this is a waiver and release of liability.