I understand that a written order may be required from a state licensed practitioner prior to receiving this ultrasound.

I understand that this ultrasound is not intended to take the place of medical diagnostic ultrasound, any other test, treatment that has been, or maybe, recommended by a doctor/healthcare provider.

I understand the importance of receiving a proper care and treatment from a doctor or healthcare provider during my pregnancy. I understand that I should contact my own doctor or healthcare provider with any questions concerning this ultrasound or any aspect of my pregnancy. I understand that I am encouraged to share the pictures from the ultrasound with my prenatal care provider.

I understand that the quality of the ultrasound images and video depends on many factors including my body tissue content, developmental stage, and fetal position. I understand that 3D 4Baby ultrasound boutique does not guarantee quality or the ability to visualize any characteristics of the fetus. I understand at 3D 4Baby ultrasound boutique will do their best to determine gender, when requested, but that gender determination is not 100% guaranteed

I understand that the total scanning session time will not exceed 20 minutes per fetus.

I understand at this time there are no known or proven harmful effects from ultrasound on the mother or fetus. If future research or other information disclose harmful or adverse effects, I agree that I will not hold 3D 4Baby ultrasound boutique, it's technicians or, it's staff liable for any future adverse findings. These elective ultrasounds are performed at your own risk.

I understand that limited information may be shared with third parties and I hear by authorize 3D 4Baby ultrasound boutique to disclose that protected medical information with those third parties. As evidenced by my signature below. I understand that I have the right to revoke this authorization at any time provided that the revocation is in writing and delivered to 3D 4Baby ultrasound boutique. I understand that authorizing the disclosure of this health information is voluntary. I understand that I may inspect or copy information to be used or disclosed, as provided in C.F.R. 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure, and the information may not be protected by the federal confidentialities rules.

Hi here by release 3D 4Baby ultrasound boutique and their agents, members, managers, affiliates, directors, physicians, and/or employees from any and all claims, damages, cause of action, or suits, whether known or unknown, whether arising now or in the future, which arise from indoor relate to this ultrasound.Hi here by release 3D 4Baby ultrasound boutique and their agents, members, managers, affiliates, directors, physicians, and/or employees from any and all claims, damages, cause of action, or suits, whether known or unknown, whether arising now or in the future, which arise from indoor relate to this ultrasound.