Prenatal Verification Form
PLEASE BRING THIS FORM TO YOUR APPOINTMENT
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Baby's Debut 3D/4D Imaging
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
HOME ADDRESS: ______________________________________________________________
CITY, ZIP: _____________________________________________________________________
PHONE: (HOME) ____________________________ (WORK) ___________________________
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: _________________
“It was amazing ! The room was so big and comfortable and the sono tech was awesome and really took her time with us. They even had toys for my daughter to play with when she started getting antsy.”
“Just had our 3D ultrasound done by Colleen. She was wonderful and did a great job at getting some awesome pictures of our babygirl!!”
“Took my daughter and her boyfriend here to have a sneak peek at the baby’s gender. It’s a beautiful place, the lady that took care of us was very polite and thorough. I highly recommend going here.”