Waiver

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 Mother Nurture, 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 DVD, or other audio visual media, depends upon many factors including;
body tissue content, developmental stage and fetal position.
– You understand that Mother Nurture does not guarantee the quality of the DVD, 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
Mother Nurture, is strictly prohibited.

– You give permission for Mother Nurture 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 DVD 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 some cases where we have determined we can possibly get better images at a later date, 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 Mother Nurture 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.
– It is the client’s responsibility to know an accurate due date for the baby. If the due date is wrong, and the baby is not far enough along gestationally to get photos or determine the sex, we will not provide a free rescan or a refund.
– Bring back appointments can only be schedule Monday through Thursday from 9:30 AM to 3:00 PM.

– You agree that you have read and reviewed the details of the package you purchased and fully understand what is included in that package. You agree to pay the full price of the package after the appointment regardless of the outcome of the service.

– You agree to refrain from posting any negative review or complaint, on social media, google, yelp, or other public websites. All concerns about your experience and the services you received must be made within fourteen (14) days from the day the service was received. Complaints must be addressed to the owner, Sara Gamache in person, over the phone, or through email. A negative complaint entails anything less than a 5 star review with comments that can be perceived by the average person as derogatory, defamatory, or critical to the services or staff. Failure to remove any such review within 24 hours can result in legal action against you.

– You understand that audio and video recording takes place within the ultrasound room and other areas throughout the office. It is your responsibility to notify any guests that accompany you in the room that they too are being recorded.

– You give permission to Mother Nurture Ultrasound to e-mail you promotions

IN CONSIDERATION OF THE SERVICES RENDERED, YOU AGREE TO RELEASE MOTHER NURTURE, 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 MOTHER NURTURE ULTRASOUND TO ACCURATELY DETERMINE FETAL GENDER OR OTHER CHARACTERISTICS, AND ANY DAMAGES OR INJURIES RESULTING FROM ULTRASOUND WHICH ARE NOT NOW KNOWN TO OCCUR. “I have carefully read this document and by checking the box on the appointment form online, I acknowledge that I fully understand and agree to its contents.”

Signature is required.