Moon Baby understands the importance of proper prenatal medical care for both the expectant mother and the fetus. Therefore, in order to provide our patients with an appropriate, meaningful ultrasound screening, Moon Baby requires that you: (i) certify that you are under the care of a physician or other health care provider, and that you are not obtaining this ultrasound as a replacement for, or in lieu of, standard prenatal medical care; and (ii) notify your current physician or health care provider regarding the ultrasound you receive from Moon Baby. We request that you present to Moon Baby an acknowledgement of receipt of this notice, signed by your physician or health provider, prior to performance of the ultrasound. In the event you are unable to notify your physician or health provider prior to performance of the ultrasound, you assume sole responsibility for notifying him or her as soon as practical following performance of the ultrasound. As a further condition to receiving ultrasound services from Moon Baby, you hereby acknowledge, understand and agree to the following statements: – This ultrasound: (i) is an elective procedure that I have voluntarily requested, and (ii) is not intended to take the place of a diagnostic ultrasound or any other test or treatment that has been or may be recommended by your healthcare provider. – Because of its elective nature, this ultrasound is generally not covered by insurance. Therefore, advance payment is required. – The technician who performs this ultrasound, while qualified to provide such ultrasound services, is not a doctor, nurse or healthcare provider, and cannot interpret, diagnose medical conditions from, or otherwise offer medical conclusions regarding the images produced. – As used by Moon Baby, this ultrasound is intended to provide enhanced images for the purpose of viewing fetal movement in utero. The technician will make no attempt to guarantee a medically inclusive ultrasound or fetal well being. – You understand that you are responsible for contacting your own healthcare provider if you have any questions concerning this ultrasound or any other aspect of your pregnancy. – You understand that the quality of the ultrasound and the video, or other audio visual media, depends upon many factors including; body tissue content, developmental stage and fetal position. You understand that Moon Baby does not guarantee the quality of the video, or other audio visual media, or the ability to visualize any characteristics of the fetus. – You understand that publication, presentation or distribution of any video taken during the ultrasound session, not provided by Moon Baby, is strictly prohibited. – You give permission for Moon Baby to use your child’s 3D/4D ultrasound photographs in its print collateral, video/web and magazine advertising, without payment or other consideration. You understand and agree that the photos being used are for print and display primarily in our office, but these photos and video may also be used at different venues such as local live events and used for local advertising. – You understand that while we make every effort to capture a good image of your baby, we cannot guarantee the cooperation nor the position of the baby. Sometimes if the baby’s position is face down, i.e., towards your spine, it may be difficult to see the baby’s face. In this case, a one-time complimentary rescan will be scheduled. Every baby scans differently, depending on the gestational age, position, amount of fluid, placental location and mother’s body habitus. However, we promise to make every effort to obtain the best images. If we are unable to get a good image of your baby, we have still provided the service of the 3D/4D Ultrasound thus we will not provide a refund if you are unhappy with the results. As evidenced by your signature below, you understand that factors beyond our control may also affect the ability to accurately determine the gender of the fetus, and that Moon Baby can provide no warranty or guaranty as to the accuracy of any such determination. You further understand that while ultrasound is believed to have no harmful effect on the mother or the fetus, future research or other information may disclose harmful or adverse effects that are presently unknown. IN CONSIDERATION OF THE SERVICES RENDERED, YOU AGREE TO RELEASE MOON BABY, ITS AGENTS, AFFILIATES, DIRECTORS, AND EMPLOYEES FROM ANY AND ALL CLAIMS OR CAUSES OF ACTIONS FOR INJURY, HARM, DAMAGE OR OTHER LIABILITY WHICH RESULTS FROM, OR ARE ALLEGED TO HAVE RESULTED FROM, THIS ULTRASOUND, INCLUDING, BUT NOT LIMITED TO, THE FAILURE OF A MOON BABY ULTRASOUND TO ACCURATELY DETERMINE FETAL GENDER OR OTHER CHARACTERISTICS, AND ANY DAMAGES OR INJURIES RESULTING FROM ULTRASOUND WHICH ARE NOT NOW KNOWN TO OCCUR.
WAIVER OF LIABILITY