Suffolk County Long Islands Sono & gender reveal party venue! Invite fam & friends!🎉
Suffolk County Long Islands Sono & gender reveal party venue! Invite fam & friends!🎉
LIABILITY WAIVER FOR ELECTIVE ULTRASOUND SERVICES
I acknowledge that I have willingly agreed to participate in an elective (not medically necessary) 3D/4D sonogram
performed by the faculty of Celebrate Life 3D. I further acknowledge and agree to the following conditions of
participation in the sonogram:
• The sonogram is NOT being performed for any type of diagnostic or medical treatment purpose.
• The sonogram is NOT being performed for the purpose of detecting any present or potential conditions/problems or complications with the health or development of the participant or her unborn baby.
• An examination report will NOT be generated for interpretation or diagnosis.
• The ultrasound will NOT be supervised or interpreted by a licensed medical provider.
• The images of the sonogram are NOT recorded nor maintained for purposes of patient diagnosis or treatment
and are NOT “medical records” for purposes of New York State consolidated laws, public health law- section 18.
The client will receive keepsake images and understands that Celebrate Life 3D will NOT maintain copies of these images.
The quality of the images varies depending on the position and gestational age of the fetus as well as other factors such
as placenta location, amount of amniotic fluid and the expectant mother’s size and weight. No refunds will be given for
any reason.
Because this is a non-diagnostic sonogram, the expectant mother must be under the care of an Obstetrician, have
medial clearance to have a 3D/4D ultrasound and have had a prior diagnostic sonogram to screen for fetal
malformations prior to having this scan.
I understand that I am waiving my rights to access and confidentiality with respect to the performance and the results of
the sonogram and for all related duplication of that information, including, but not limited to, documents, recordings,
videotape, digital information, and photographs (collectively the “materials”). I further understand that Celevrate Life 3D may disclose the Materials to faculty and students of Celebrate Life 3D.
To the fullest extent permitted by law, the client hereby releases and holds harmless, and agrees to indemnify, Celebrate Life 3D, its officers, directors, shareholders, members, agents, employees, independent contractors, faculty and
students (the Celebrate Life 3D “parties”), against all claims arising from (a) any personal injury, bodily injury or
property damage whatsoever occurring in or at Celebrate Life 3D or from the participation in the sonogram, (b) any
personal injury resulting from the failure to disclose any health condition reasonably requested to be disclosed orally or
in writing prior to the participation in the sonogram, or (c) the use or disclosure of the materials by the undersigned , the
undersigned unborn baby and their personal representatives, executors, heirs or assigns, except to the extent caused by
the negligence or willful misconduct of Celebrate Life 3D . I agree to defend, indemnify and hold harmless Celebrate Life 3D and Celebrate Life 3D parties from any claim I should make in violation of this agreement.
I HAVE CAREFULLY READ THE AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AGREE TO THE TERMS AND CONDITIONS OF THIS WAIVER OF LIABILITY.
Print Name: ___________________
Sign Name:_____________________
Date:__________________________
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