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Baby's Debut 3D/4D Imaging

(315) 525-0818

 

ALBANY OFFICE                                  SYRACUSE OFFICE                              UTICA OFFICE

6 Automation Lane                                716 James Street                                  8540 Seneca Turnpike   

Albany, NY 12205                                 Syracuse, NY 13202                             New Hartford, NY 13413

 

Client Information & Waiver

 

 

NAME: ________________________________________________________________________

 

HOME ADDRESS: ______________________________________________________________

 

CITY, ZIP: _____________________________________________________________________

 

PHONE: (HOME) ____________________________ (WORK) ___________________________

 

EMAIL:________________________________________________________________________

 

DOCTOR NAME: _______________________________________________________________

 

DOCTOR ADDRESS: ____________________________________________________________

 

DOCTOR PHONE: _________________________________ DUE DATE: __________________

   

HOW DID YOU HEAR ABOUT US: ________________________________________________

 

Prenatal Care: I acknowledge that I have been informed by Baby’s Debut that prenatal care is important to a healthy pregnancy. I am currently receiving prenatal care.

 

Concerns Should Be Referred to Physician: I have also been informed by Baby’s Debut that use of Baby’s Debut services cannot substitute for care of a physician. If I have any concerns regarding my pregnancy, I will contact my doctor. I will in no way rely upon Baby’s Debut or its services for medical advice.

 

No Professional Negligence Claims: I am purchasing Baby’s Debut services and products for keepsake, non-medical purposes. I agree that I have no right to recourse against Baby’s Debut in any medical malpractice, professional negligence or any medical related claim arising out of or in any way related to my pregnancy or the birth of my child. This includes any claim for error in gender determination.

 

Assumption of Risks: I acknowledge that there is inherent risk in any activity involving a fetus and there are potential risks in this type of activity. I understand Baby’s Debut follows FDA recommendations for length of scan and frequency of ultrasound sound waves, and that no detrimental effects have been found in 40 years of studies. I hereby voluntarily assume all risk of harm or injury to me or my baby resulting from the services provided by Baby’s Debut.

 

Waiver and Release of Claims: I hereby waive, release, acquit and forever discharge Baby’s Debut from any and all claims, expenses, demands, costs, causes of action, and other actions and liabilities, of any nature whatsoever, whether known or unknown, whether in law or equity, that I or my baby may have arising out of or in any way related to my visit to Baby’s Debut. I agree that I shall have no right whatsoever to file any lawsuit or institute any other action or legal proceedings of any type arising out of or in any way related to my visit to Baby’s Debut.

 

Photo Release: I give Baby’s Debut permission to post or use any photos or recorded data for advertisement purposes. I understand no names will be posted or used with the photos.

 

Picture Quality: I understand picture quality is dependent on many factors. I understand that Baby’s Debut is not always able to obtain pictures of every baby. I understand no refunds are available if unable to obtain pictures or gender.

 

I understand my physician has not ordered this. I understand that this ultrasound is not to be used to replace physician care. I have been informed that the federal Food and Drug Administration has determined that the use of medical ultrasound equipment for reasons other than medical purposes, without a physician’s prescription, is an unapproved use. I have been informed that Baby’s Debut follows FDA recommendations for frequency (sound waves) and length of scan which has found no detrimental effects in 40 years of case studies.

 

 

I have read and understand all of the above. I agree to all of the above.

 

 

Signature: _______________________________________________ Date: _________________