Forms

Picture Me Baby 3D/4D Ultrasound, LLC (Company) offers elective 2D, 3D, 4D & 5D prenatal ultrasounds for entertainment and keepsakes and to provide a positive bonding experience for the mother, family members, and friends with the unborn child. This entertainment ultrasound session will not provide any assumptions, diagnosis, or medical input 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 health care provider.

I acknowledge the following:

• I am under the care of a physician or healthcare provider for the medical diagnosis, input, and recommendations relating to my pregnancy.
  
  
• I certify I am obtaining this 2D, 3D, & 4Dultrasound for entertainment only and I am not obtaining this ultrasound as a replacement for, or in lieu of, standard medical care.
  
  
• I have undergone a medical diagnostic ultrasound prescribed by my healthcare provider in regard to this pregnancy. My healthcare provider ultimately will confirm my due date, and screen for fetal abnormalities, and/or any abnormalities related to my pregnancy.
  
  

As a condition of receiving an entertainment ultrasound from Picture Me Baby 3D, 4D Ultrasounds, LLC, I, hereby acknowledge, understand, and agree to the following statements:

• This ultrasound is an elective, non-medical procedure that I have voluntarily requested.
  
  
• I realize this ultrasound session is not intended to take the place of a diagnostic ultrasound or any other tests or treatments that have been or may be recommended by my healthcare provider.
  
  
• The technician performing the ultrasound is not a doctor, and cannot interpret diagnostic medical conditions, or otherwise offer medical conclusions regarding the images. The ultrasound session(s) is intended for entertainment purposes only. The technician will not attempt to provide a medically inclusive ultrasound or confirm fetal well-being.
  
  
• I understand I am responsible for contacting my healthcare provider if any questions arise concerning any issues relating to this ultrasound session or any aspect of my pregnancy. Picture Me Baby, LLC has my permission to videotape and photograph my baby and me and has full editing rights to the media.
  
  
• I hereby agree to allow Picture Me Baby, LLC, its agents, and employees the use of photos, videos, 3D/4D/5D movie in whole or in part, such media may be published, reproduced, exhibited, and copyrighted. They can be used and published anywhere in the world in connection with Picture Me Baby, LLC for any manner whatsoever without further authorization or consent from or payment to me.
  
  
• I further realize providing any written feedback/testimonial allows Picture Me Baby authorization for its use in marketing.
  
  
• I realize Picture Me Baby may use my email for their marketing. I realize and understand the quality of my ultrasound images depends upon many factors including body content, fluid levels, developmental stage, and fetal position. I understand Picture Me Baby, LLC, does not guarantee the quality of the images or the ability to visualize any characteristics of the fetus. Picture Me Baby, LLC will do everything reasonable to optimize the baby’s position in the timeframe allotted in the package I selected. If a rescan is warranted, I understand I get one additional rescan at no charge, if I request additional scans, a fee of half the price of the original package purchased will be required and charged to me at time of service. All sales are final and refunds are not granted for any services rendered.
  
  
• In the event you are scheduled for a second session, rescan, follow-up session..etc and unforeseen circumstances occur, (fetal demise, early delivery, scheduling conflicts, moving out of state..etc) You are fully aware you will forfeit that session and funds are non-refundable.
  
  
• I further understand that factors beyond Picture Me Baby, LLC'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 further understand that while ultrasound is believed to have no harmful effects on the mother or the fetus, further research or other information may disclose harmful or adverse effects that are presently unknown. In consideration of the services rendered, I agree to release and hold harmless Picture Me Baby, LLC and its agents and employees (all referred to as the “released parties”), from any and all claims or causes of action for injury, harm, loss, damage, or other liability, whether caused by the negligence of the released parties or otherwise that result from or are alleged to have resulted from this ultrasound.
  
  

In addition, I agree to release and hold harmless the released parties from any and all claims or causes of action for injury, harm, loss, damage, or other liability which results from, or are alleged to result from, the failure of the released parties to accurately determine fetal gender or any other characteristics of the fetus. I will indemnify Picture Me Baby, LLC with respect to any complaint and will agree to arbitration in the state of North Carolina if any disagreements occur.