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PEEK-A-BOO WAIVER & RELEASE

  • The undersigned, _____________________________acknowledges and agrees that these ultrasound services and imaging are not medical procedures and are not offered as a medical treatment or diagnosis in any manner.

  • Further, the ultrasound services and imaging are not for the purposes of determining or to be used in the future to determine the health status of the fetus(es) and the undersigned mother or the fetus(es) at this time, during the pregnancy or at the birth of the fetus(es).

  • Further, the undersigned acknowledges and agrees that the ultrasound services and images are for entertainment purposes only and are not to be used at any time for the purposes of any medical diagnosis, treatment or care of the fetus(es) or mother.

  • The undersigned mother further declares that she is under the care of a qualified physician regarding her pregnancy at the time of the ultrasound services and imaging.

  • The undersigned agrees and acknowledge that under no conditions will Peek-A-Boo LLC, its staff, agents, or employees be held liable or accountable for any consequences of any known or unknown medical condition of the mother and the fetus(es) or for failure to diagnose, treat or inform said undersigned of any known or unknown medical conditions, risks or problems regarding the undersigned mother and fetus(es)

  • Further, the undersigned agrees and acknowledge that no guarantee can be made or has been made at the time of the imaging as to the picture or video quality and/or content of the imaging due to circumstances beyond the control of Peek-A-Boo LLC, its staff, agents and employees, including, but not limited to the position of the fetus(es), position of the placenta or position of the internal organs of the mother.

  • Under no circumstances will Peek-A-Boo LLC, its employees, agents, or staff be held liable for any injury or damages that may occur to undersigned or of the fetus(es) as a result of any ultrasound performed on the undersigned mother by Peek-A-Boo LLC, its employees, agents, or staff.

  • By signing this document, the undersigned releases, acquits, hold harmless and forever discharges Peek-A-Boo LLC, its staff, agents, and employees from all matters of foreseen or unforeseen claims, demands, damages, actions, or causes of action by the undersigned individually and/or on the behalf of the fetus(es), resulting from any ultrasound imaging performed by Peek-A-Boo LLC. In signing this waiver, I certify that I have carefully read and understand this liability waiver and release.

      Email Address ________________________________________________

      Phone _____________________________Date of Birth _______________________

      Estimated Due Date ____________________

      Can we post your 3D/4D HD pictures to our website or social media? ____ Yes ____No

      Doctor’s Name _________________________________

      Doctor’s Address _______________________________

      Doctor’s Phone Number ________________________

*FOR REVIEW ONLY YOUR MEMORY COORDINATOR WILL PROVIDE COPY FOR SIGNATURE*

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