Registration & Release Form

Pregnant Clients ONLY: Must complete this form before your session.
Workshop Takers: Skip this form. Just fill consent form provided to you via email.

You or your spouse ACTIVE DUTY?

YES - have valid ID

First name

Last name

Phone

Date of birth

Due Date

Name of Current Obstetrician/Midwife*

Had 1st ultrasound

Yes

Scheduled

Waiting to be scheduled.

Provider's Phone number

Scheduled date.

Date of First OR Last ultrasound

Were the results normal?*

YES

Pending Results

Comments:

By submitting this form, I verify the accuracy of the information above. I authorize Island Country Ultrasound to disclose my medical information to my healthcare provider if necessary.*

Release & Waiver of Liability

By submitting this form, I acknowledge that Island County Ultrasound provides elective 2D, 3D, 4D 5D & HD prenatal ultrasounds for entertainment, keepsake and to provide a positive bonding experience for the expectant mother, family members, and friends with the unborn child. This entertainment ultrasound session will not provide any assumptions, diagnosis, medical input or care of any kind and is not intended to take the place of a diagnostic ultrasound or any other medical procedure(s) recommended by your physician or healthcare provider.

Island County Ultrasound, I hereby acknowledge, understand and agree to the following statements.

I am under the care of a physician or other health care provider, and am receiving current prenatal care for this pregnancy.
I am not obtaining this entertainment ultrasound as a replacement for, or in lieu of, standard prenatal medical care.
This ultrasound is an elective, non-medical procedure that I have voluntarily requested.
This ultrasound is not covered by my health insurance.
The ultrasound session(s) is intended for entertainment purposes only to view fetal movements. The sonographer will make no attempt to provide a medically inclusive ultrasound or confirm fetal well-being.
The sonographer who performs this ultrasound is not a doctor and cannot interpret, diagnose medical conditions from, or otherwise offer medical conclusions regarding the images obtained. I understand that the images will not be reviewed by a radiologist or physician.
I agree that I have no right of recourse against Island County Ultrasound or my physician for any medical malpractice, professional negligence or medically related claims arising out of the use of this keepsake service.
I will not rely on any information, either written, verbal or otherwise, that is received from Island County Ultrasound for any purpose whatsoever, including, but not limited to, medical decision making.
I understand that I am responsible for contacting my own healthcare provider if I have any questions concerning this ultrasound or any other aspect of my pregnancy.
I give Island County Ultrasound permission to post and/or use any media in the form of still images or moving images for advertising purposes. I understand no names will be posted or released in association with these images or videos.
I realize and understand that the quality of my ultrasound images depends upon many factors including my body habitus, fetal position, developmental stage, and adequate fluid. I understand Island County Ultrasound does not guarantee the quality of the images or the ability to visualize any characteristics of the fetus such as gender and all images are not stored.
Island County Ultrasound will make every reasonable effort to optimize the baby's position and to obtain good images in the time frame allotted in the package I selected. However, there is no guarantee of the cooperation nor the position of the baby. I understand Island County Ultrasound is not always able to obtain good images of every baby at every session. I understand that this is a service and that no refunds are available, even if we are unable to get a good image of the baby.
If a rescan is warranted, and applicable to the package I selected, I understand I get one free rescan at no charge. All rescans must take place within 10 days of the original appointment, and can only be scheduled for a weekday. Rescans are not available on any weekends or holidays. If I request an additional rescan, a fee of half the price of the original package purchased will be required and charged to me at time of service. I understand that if I decline the free rescan offered to me, I will not receive a refund or discount of any kind.
I understand that factors beyond Island County Ultrasound's control may also affect the ability to accurately determine the gender of the fetus, and that there is no warranty or guarantee as to the accuracy of any such determination. I understand that gender cannot ever be guaranteed 100% before birth.
I further understand that while ultrasound is believed to have no harmful or adverse effects on the mother or the fetus, future research or other information may discover adverse effects that are presently unknown.
In consideration of the services rendered, I agree to release Island County Ultrasound LLC, it's 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 Island County Ultrasound ultrasound to accurately determine fetal gender or other characteristics, abundant damages or injuries resulting from ultrasound which are not known to occur.
“I have carefully read this document and by signing at the bottom, I acknowledge that I fully understand and agree to its contents.”

Your Signature

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