New Client Intake Forms

Please fill out the following New Client Intake form prior to your appointment with us!
Have you informed your doctor of your visit to our facility?
Have you had any problems with your current pregnancy?
Were the results normal?
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What are you having?
May we share your baby’s pictures/video clip on our Social Media?

 (Your names and personal details will NEVER be shared - only photos of your amazing baby!)

TERMS & CONDITIONS

I understand that services provided by Growing Love Ultrasound Studio are a limited elective ultrasound and do not replace any diagnostic ultrasounds ordered by my OB provider.

I verify the accuracy of the information above. I authorize Growing Love Ultrasound to disclose medical information to my healthcare provider if necessary. I agree that I am financially responsible for charges related to this elective ultrasound. I understand that all sales are final.

COVID-19 AGREEMENT

The coronavirus (COVID-19) has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies have provided recommendations, such as social distancing. 

Growing Love Ultrasound has put in place preventative measures to reduce the spread of COVID-19; however, Growing Love Ultrasound cannot guarantee that you/guests/clients will not become infected with COVID-19. Furthermore, participation in any activities including your appointment at Growing Love Ultrasound could increase your risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by appearing for my appointment at Growing Love Ultrasound and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand the risk of becoming exposed to or infected by COVID-19 at Growing Love Ultrasound may result from the actions, omissions, or negligence of myself and others, including but not limited to, Growing Love Ultrasound employees and other clients. 

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself or my family (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my appointment at Growing Love Ultrasound.

I hereby release, covenant not to sue, discharge, and hold harmless Growing Love Ultrasound, its employees, contractors, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of Growing Love Ultrasound, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Growing Love Ultrasound connection. I understand that I may be asked to leave the premises if Growing Love Ultrasound has any hesitations or suspicions of my physical or mental health.

WAIVER OF LIABILITY

Growing Love Ultrasound 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 screening, Growing Love Ultrasound requires that you: (i) certify that you are under the care of a physician or other health care provider, and that you are not obtaining this ultrasound as a replacement for, or in lieu of, standard prenatal medical care; and (ii) notify your current physician or health care provider regarding the ultrasound you receive from Growing Love Ultrasound.

 

We request that you present to Growing Love Ultrasound an acknowledgement of receipt of this notice, signed by your physician or health provider, prior to performance of the ultrasound. In the event you are unable to notify your physician or health provider prior to performance of the ultrasound, you assume sole responsibility for notifying him or her as soon as practical following performance of the ultrasound.

 

As a further condition to receiving ultrasound services from Growing Love Ultrasound, 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 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 Growing Love Ultrasound, 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 Growing Love Ultrasound 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 Growing Love Ultrasound, is strictly prohibited.

 

– 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 this case, 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 Growing Love Ultrasound 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.

 

IN CONSIDERATION OF THE SERVICES RENDERED, YOU AGREE TO RELEASE GROWING LOVE ULTRASOUND, 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 GROWING LOVE 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 signing at the bottom, acknowledge that I fully understand and agree to its contents.”

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