Release Waiver of Liability for 2D/3D/4D Ultrasound
Little Peek Boutique offers elective 2D/3D/4D ultrasounds for entertainment keepsakes only. This session will not provide any assumptions, diagnosis or medical input; it is not intended to take place of a diagnostic ultrasound or any other medical procedures recommended by your health care provider.
I acknowledge the following:
- I am under the care of a health care provider for the medical diagnosis, input, and recommendations related to my pregnancy.
- I certify I am obtaining this elective ultrasound for entertainment purposes only and is not a replacement for, or to be used in lieu of, standard medical care.
- I have undergone a previous medical diagnostic ultrasound prescribed by my health care provider in regards to this pregnancy.
As a condition of receiving this ultrasound from Little Peek Boutique, I hereby acknowledge, understand and agree to the following statements:
- This ultrasound is an elective, non-medical procedure that I have voluntarily requested. There will be no attempt to advise or provide confirmation of fetal well-being.
- The person performing this ultrasound cannot interpret diagnostic medical conditions or offer medical conclusions regarding images.
- I am responsible for contacting my health care provider should any questions arise.
- The obtained images will not be reviewed by a physician or radiologist. I have no right of recourse against Little Peek Boutique for any medically related claims.
- I give Little Peek Boutique permission to use any images for advertising purposes. I understand no names will be released in association with these images.
- The quality of my ultrasound image(s) depends on many factors; including but not limited to: body habitus, developmental stage, fetal position or adequate amniotic fluid. Little Peek Boutique makes no guarantee in quality of the images or the ability to visualize characteristics.
- There is no guarantee in the accuracy of a gender determination, and no refunds.
- In consideration of services rendered, I release and hold harmless Little Peek Boutique and/or its agents from any and all claims or causes of action for injury, harm, loss, damage, or other liability. I will indemnify Little Peek Boutique with respect to any complaint.
I have carefully read and understand this release of liability and hereby acknowledge that I fully understand and agree to its contents.