I verify that the above obstetrician information that I have provided above is true and accurate to the best of my knowledge. If necessary, I authorize Sweet Baby Imaging of TN, it's representatives and/or employees, to disclose medical information to my OB Provider listed above at any point within this pregnancy. I agree that I am financially responsible for all charges related to my ultrasound(s).
I am receiving ongoing prenatal care and my OB provider is that of whom is stated above. I have been given a due date of that of which is stated above. I understand that this is a limited ultrasound and does not replace any screening and/or diagnostic ultrasound(s) ordered by my current physician or healthcare provider.
(Gender determination visit) I understand that this ultrasound may not last more than 10 minutes and will focus on my baby's pelvic area and I understand that there is a very small possibility that the wrong gender may be assigned to my baby. I agree not to hold Sweet Baby Imaging of TN responsible as well I agree to reach directly out to Sweet Baby Imaging of TN to discuss any concerns if this issue would arise as I understand that it is their policy of a refund and/or free ultrasound session in this pregnancy if the wrong gender were assigned. Although I understand that this is unlikely to arise, there are circumstances that can make it difficult for the staff to determine the gender accurately and they do agree to try their best to be as accurate as possible and if at any time Sweet Baby Imaging of TN feels that there is a need to return for a scan redo to increase the gender accuracy, that they will let client know, which can prolong the gender determination from the original appointment date.
Sweet Baby Imaging of TN understands the importance of proper prenatal medical care for both the expectant mother and the fetus; therefore, to provide our clients with an appropriate, meaningful ultrasound screening, Sweet Baby Imaging of TN requires that you, the client: certify that you are under the care of a physician or other healthcare provider; you are not obtaining this ultrasound as a replacement for or in lieu of any standard prenatal medical care; you will notify your current physician or other healthcare provider regarding any ultrasounds you receive from Sweet Baby Imaging of TN.
We request that you present to Sweet Baby Imaging of TN an acknowledgement of receipt of this notice, evidenced by your signature below, prior to performance of the ultrasound(s). You also assume sole responsibility to notify your current physician or healthcare provider prior to performance of your ultrasound(s) or as soon as practical following the performance of any ultrasounds; however, Sweet Baby Imaging of TN may release information to your current physician or healthcare provider if deemed necessary for their review or intervention. As a further condition to receiving any ultrasound services from Sweet Baby Imaging of TN, you hereby acknowledge, understand and agree to the following statements:
- This ultrasound is an elective procedure that I have voluntarily requested and is not intended to take the place of a screening or diagnostic ultrasound or any other test or treatment that has been or may be recommended by my current physician or healthcare provider.
- Because of its elective nature, this ultrasound is generally not covered by insurance; therefore, advance payment is required.
- The technician performing the ultrasound, while qualified to provide such ultrasound services, is not a medical doctor, nurse or healthcare provider and cannot interpret, diagnose medical conditions from or provide any medical advice regarding the images produced.
- As used by Sweet Baby Imaging of TN, this ultrasound is intended to provide enhanced images for the sole purpose of viewing fetal movements 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 current physician or healthcare provider regarding any medical questions concerning this ultrasound or any aspect of your pregnancy.
- While the Sweet Baby Imaging of TN technician will make every effort to obtain a quality ultrasound and video, you understand that the quality of the ultrasound and video depends upon many factors including, but not limited to, body tissue content, developmental stage, as well as fetal position. You understand that Sweet Baby Imaging of TN does not guarantee the quality of the video or the ability to visualize any characteristics of the fetus.
