Love In 3D Mobile Ultrasound
3D/4D ELECTIVE ULTRASOUND CONSENT & WAIVER FORM
1. NON-DIAGNOSTIC
PURPOSE I understand that the 3D/4D ultrasound I am receiving is purely elective and not intended for medical diagnostic purposes. This session does not replace a physician’s prenatal care or diagnostic ultrasound. The ultrasound technician will not provide medical advice, diagnoses, or measurements. I have been advised to contact my healthcare provider for any medical concerns.
2. ELIGIBILITY & RESPONSIBILITY
I confirm that I am currently under the care of a licensed prenatal healthcare provider and am not obtaining this scan as a substitute for medical evaluation. I release Love In 3D Mobile Ultrasound and its staff from any liability related to the interpretation or use of the images.
3. IMAGE QUALITY ACKNOWLEDGMENT
I understand that image clarity depends on factors such as baby’s position, amniotic fluid levels, gestational age, and maternal body type. I acknowledge that no specific results or number of images are guaranteed.
4. PHOTO/VIDEO RELEASE
I give permission
I do not give permission for Love In 3D Mobile Ultrasound to use my ultrasound photos or videos for marketing, social media, or promotional purposes.
5. RELEASE OF LIABILITY
I hereby release Love In 3D Mobile Ultrasound, its technicians, and affiliates from any claims or damages arising from participation in this elective session.
6. CLIENT CONFIRMATION
By signing below, I acknowledge that I have read, understood, and voluntarily agree to the terms of this consent and waiver.
Client Signature:
Technician Signature:
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