CMB Imaging LLC requires a minimum of 24 hours notice for cancellation without penalty. If the client cancels within the 24 hours of the appointment, the client forfeits the money paid. Clients may however reschedule to a different date and time without penalty if the client reschedules more than 24 hours in advance. In this situation, one reschedule will be allowed. CMB Imaging LLC understands the importance of proper prenatal medical care for both the expectant mother and the fetus. Therefore, in order to provide our patients with an appropriate, meaningful ultrasound experience, CMB Imaging LLC requires you (i) certify that you are under the care of physician or other healthcare provider for this pregnancy, and that you are not obtaining this ultrasound as a replacement for in lieu of, standard prenatal medical care, and (ii) that you provide CMB Imaging LLC with the name and phone number of your healthcare provider. CMB Imaging LLC requires that all clients have had at least one ultrasound with a healthcare provider. As a further condition to receiving ultrasound services from CMB Imaging LLC, you hereby acknowledge, understand, and agree to the following statements: -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 my healthcare provider. Because of its elective nature, this ultrasound is not covered by insurance. Therefore, advance payment is required. -the technologist who performs this ultrasound, while qualified to provide such ultrasound service is not a doctor, nurse, or healthcare provider and cannot interpret or diagnose medical conditions from, or otherwise offer medical conclusions regarding the images produced. -As used by CMB Imaging LLC, this ultrasound is intended to provide enhanced images for the purpose of viewing fetal movements in utero. The technologist will make no attempt to guarantee a medically inclusive ultrasound or fetal well-being. -I understand that the quality of the ultrasound pictures and videos depend upon many factors, including body tissue content, developmental stage, and fetal position. I understand that CMB Imaging LLC does not guarantee the quality of the pictures or videos or the ability to visualize any characteristics of the fetus. -I give CMB Imaging LLC permission to post or use any photos or recorded data for advertisement purposes. I understand that name, date of birth or any other identifying information will NOT be posted or used with the photos. -I understand that no refunds will be available in the event that CMB IMaging LLC is unable to obtain pictures or gender. However, in the event that the technologist is unable to determine gender, the client will be brought back at a later date with no additional charge to the client. To further clarify, there are no refunds after the ultrasound service has been performed. In the event that your baby has ambiguous genitalia or any other abnormalities regarding your baby, CMB Imaging LLC is not responsible for refunds, rescans, or compensation for any items purchased. CMB Imaging LLC is not liable for any missed diagnosis of your baby. CMB Imaging LLC is not liable for any injuries incurred while on the premises. If you or your family member break anything while at CMB Imaging LLC, you agree to take full responsibility to have it replaced. All payments must be collected prior to your elective ultrasound. No refunds are given after the service has been performed. ******************************************************************************************************* As evidenced by your signature/typing your name below, you understand that factors beyond CMB Imaging LLC control may also affect the ability to accurately determine the gender of the fetus, and that gender reveal cannot be guaranteed. CMB Imaging LLC can provide no warranty or guarantee as to the accuracy of any such determination. You further understand that while ultrasound is believed to have no harmful effects on the mother or the fetus, future research or other information may disclose harmful or adverse effects that are presently unknown. In consideration of the services rendered, you agree to release CMB Imaging LLC, its agents, affiliate, directors and employees from any and all claims or causes of actions for injury, harm, damage, or any other liability which results from or are alleged to have resulted from this ultrasound, but not limited to the failure of CMB Imaging LLC to accurately determine fetal gender or other characteristics and any damages or injuries resulting from ultrasound which are not now known to occur. This is not a medical exam if any anomalies are not visualized CMB Imaging LLC is not responsible. Diagnostic medical exams should be obtained through your provider. I have carefully read this document and by signing my name, I acknowledge and agree to its content. ___________________________________________ Date ______________________