Release Waiver of Liability for 2D/3D/4D Ultrasound

          Little Peek Boutique offers elective 2D/3D/4D ultrasounds for entertainment keepsakes only.  This session will not provide any assumptions, diagnosis or medical input; it is not intended to take place of a diagnostic ultrasound or any other medical procedures recommended by your health care provider.

I acknowledge the following:

1. I am under the care of a health care provider for the medical diagnosis, input, and recommendations related to my pregnancy.
2. I certify I am obtaining this elective ultrasound for entertainment purposes only and is not a replacement for, or to be used in lieu of, standard medical care.
3. I have undergone a previous medical diagnostic ultrasound prescribed by my health care provider in regards to this pregnancy.

As a condition of receiving this ultrasound from Little Peek Boutique, I hereby acknowledge, understand and agree to the following statements:

• This ultrasound is an elective, non-medical procedure that I have voluntarily requested.  There will be no attempt to advise or provide confirmation of fetal well-being.
• The person performing this ultrasound cannot interpret diagnostic medical conditions or offer medical conclusions regarding images.
• I am responsible for contacting my health care provider should any questions arise.
• The obtained images will not be reviewed by a physician or radiologist.  I have no right of recourse against Little Peek Boutique for any medically related claims. 
• I give Little Peek Boutique permission to use any images for advertising purposes.  I understand no names will be released in association with these images.
• The quality of my ultrasound image(s) depends on many factors; including but not limited to: body habitus, developmental stage, fetal position or adequate amniotic fluid.  Little Peek Boutique makes no guarantee in quality of the images or the ability to visualize characteristics. 
• There is no guarantee in the accuracy of a gender determination, and no refunds.
• In consideration of services rendered, I release and hold harmless Little Peek Boutique and/or its agents from any and all claims or causes of action for injury, harm, loss, damage, or other liability.  I will indemnify Little Peek Boutique with respect to any complaint.

I have carefully read and understand this release of liability and hereby acknowledge that I fully understand and agree to its contents.