gender check ultrasound - Utah Valley OB Ultrasound

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GENDER CHECK ULTRASOUND
Payment of $45.00 is Due at time of service. Check box for optional DVD $20.00 - DVD purchase includes digital
pictures emailed to you to forward to friends and family. Visit utahultrasound.com
($5.00 additional charge for debit/credit card applies) We do not accept checks for gender check ultrasounds.
I authorize UVOB Ultrasound to charge my credit card for this ultrasound. I accept all charges and fees.
Signature:________________________Date:________ Cash: __Credit Card/Exp Date:__________________________
Name___________________________________ Husband/Parent__________________________________________
Age________ Date of Birth_________________ Emergency Contact_________________Phone_________________
Address__________________________________ Physician:________________ Referred By:___________________
City_______________State___ Zip____________ Employer_________________Work Phone___________________
Phone________________Cellphone____________ Email Address__________________________________________
The gender check ultrasound will take approximately five minutes. Please allow extra time for paperwork and
waiting time. Although the ultrasound technologist will do their best to bring you back at your scheduled time,
please be aware that any medical exam will take precedence over gender checks. In this setting it is not always
possible to stay exactly on schedule. Emergency exams arise and this can put the rest of the schedule behind.
It is understood that I, ____________________________have contacted or will notify my physician or healthcare
provider that I have chosen to receive this ultrasound. I understand that the purpose of this ultrasound is to view fetal
movements inside the uterus in a non-medical setting.________Initial.
I also understand the necessity of medical supervision for my own prenatal care. I understand that this ultrasound, in no
way or form, replaces a medical diagnostic ultrasound or any other treatment that has been or may be prescribed by a
doctor or healthcare provider. I also understand that I am solely responsible for contacting my own physician or
healthcare provider with any concern relating to this ultrasound or my pregnancy in general._________Initial.
I understand that the technician performing the ultrasound is not a doctor and will make no attempt to evaluate fetal wellbeing, assess size and dates, rule out birth defects or malformations. The technician will not make a medical diagnosis. A
MEDICAL ULTRASOUND MUST BE DONE FOR DIAGNOSTIC INFORMATION. I AGREE TO NOT ASK ANY
QUESTIONS TO THE TECHNICIAN RELATED TO FETAL CONDITION INCLUDING SIZE AND DATES. I
agree to take any concerns I may have to my doctor. _______Initial.
I understand the image quality obtained on this ultrasound is affected by fetal age, fetal position, and FETAL
COOPERATION. I also understand image quality is affected by my body size(tissue type thickness) and amniotic fluid
levels. I UNDERSTAND THAT THE GENDER CANNOT ALWAYS BE ACCURATELY DETERMINED
UNDER ALL CIRCUMSTANCES. I WILL NOT HOLD UTAH VALLEY OBSTETRICAL ULTRASOUND, IT’S
OWNER, AND OR EMPLOYEES RESPONSIBLE FOR ERRORS IN ATTEMPTING TO DETERMINE THE
GENDER, QUANTITY, OR CHARACTERISTICS OF THE FETUS(S).______Initial.
I understand that ultrasound is currently believed to have no harmful effects on the mother or fetus; however, if future
findings disclose that ultrasound causes harmful or adverse effects to either the mother or the fetus, I WILL NOT HOLD
UTAH VALLEY OBSTETRICAL ULTRASOUND, ITS OWNERS, OR TECHNICIANS LIABLE FOR ANY FUTURE
ADVERSE FINDINGS.______Initial.
I understand that Utah Valley Obstetrical Ultrasound is a SEPARATE ENTITY from my doctor’s office and I
agree not to discuss this ultrasound with my doctor. I understand that payment is required at the time of service. I
AGREE TO PAY ALL COLLECTION FEES OF 50% OF THE UNPAID BALANCE TURNED TO COLLECTION
AND COURT COSTS INCLUDING ATTORNEY FEES in connection with this collection process. I understand if my
payment does not go through, or if I do not pay the entire amount owed for this ultrasound on the date of service, I
will be charged a billing fee of $25 per month that balance is owed. Interest shall also accrue at 1.5% per month on
any unpaid balances. I also give my consent to have this gender check ultrasound. __Initial.
I hereby release Utah Valley Ob Ultrasound, it’s owners, agents, affiliates, technicians, or any employees from any and all
claims, damages, accusations or suits which may arise during the pregnancy or develop in the future as a result of this
ultrasound. I accept the terms of this document and by signing, I acknowledge that I fully understand and agree to its
contents.
SIGNATURE______________________________________________________________ DATE__________
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