3D/4D Consent Form

PLEASE READ COMPLETELY AND CAREFULLY BEFORE SIGNING

 

I,_____________________________________________, grant permission to CMB Imaging to perform an elective 3D/4D sonogram.

Ultrasounds for fetal portraits are not medically necessary and are not covered by any health insurance plan or flexible spending account.  The full amount of your appointment will be paid prior to the exam.  

I understand that this 3D/4D sonogram does not replace a routine diagnostic sonogram for the purpose of screening for genetic disorders, fetal anomalies, fetal growth assessment and fetal well-being.  I understand that CMB Imaging will perform the 3D/4D ultrasound only if I can prove that (1) I am receiving prenatal care from a licensed provider and (2) have undergone a medical diagnostic sonogram to confirm my due date, screen for anomalies, and diagnose any other pregnancy related issues.  

I understand that the 3D/4D sonogram is elective in nature and is for the entertainment purposes only.  I understand that CMB Imaging cannot guarantee the accuracy of the 3D/4D images due to the unpredictable nature of my baby.  Additionally, I understand that the images of my baby are not true depictions of how my child will appear after birth.  Furthermore, I understand that there is a chance that during my visit my baby may not be optimally positioned (i.e. face down to my spine, up against my placenta, hands in front of face, etc.).  I understand that CMB Imaging will try to accommodate me to the best of its ability and may ask me to return at a different time/day in such circumstances.  I understand that all patients can scan differently depending on gestational age, fetal position, amount of amniotic fluid, placental location, and maternal weight and my 3D/4D image may not be similar to those I have seen elsewhere.

If any illness, injury, or accident occur which, in the sole judgment of the staff of CMB Imaging, requires immediate medical attention, I give consent to terminate the 3D/4D sonogram, and I understand that I will be referred to my acting OB/GYN provider.

For the sole consideration of CMB Imaging performing an elective 3D/4D sonogram, I hereby assume all risks of personal injury to myself and my baby in any way associated with the 3D/4D sonogram.  Three and four dimensional ultrasounds to obtain keepsake fetal portraits is elective, not medically necessary procedure.  

I hereby agree that CMB Imaging, its members individually and its officers, agents, and employees shall not be liable for any injuries or any damage to me or my baby, or be subject to any claim, demand, injury or damages, whatsoever, including without limitation, those damages from acts of passive or active negligence on the part of CMB Imaging, its members individually and its officers, agents and employees.  I expressly acknowledge that CMB Imaging will not review the 3D/4D sonogram for any purpose and that it is not a diagnostic evaluation, nor is it intended to be diagnostic.  I hereby agree to expressly forever release and discharge CMB Imaging, its members individually and its officers, agents and employees from all such claims, demands, injuries, damages, actions or cause of action.  Further, I covenant not to sue CMB Imaging, its members individually and its officers, agents and employees.  I acknowledge that I have carefully read this and fully understand that this a waiver and release liability.

I have received a copy of this document and I certify that I have read the above carefully before signing.

This______________ day of_____________, 20

 

 

Signature of witness

 

Signature of patient