3501 Del Prado Blvd, South, Cape Coral, Suite 210, 2nd Floor
CONSENT TO NON-MEDICAL ELECTIVE ULTRASOUND
By signing this agreement, I consent to Peek a Boo Baby 3D/4D, LLC. conducting an elective ultrasound exam
(Ultrasound) strictly and solely for entertainment purposes. I acknowledge and agree the Ultrasound is not being
considered or conducted for medical or diagnostic purposes, nor will any medical information be obtained, discussed, or
provided to me through Ultrasound. All information obtained by this Ultrasound through either direct viewing of the
video monitor, or any photographs, DVD, or other media is strictly and exclusively for entertainment purposes and not in
any manner for medical or diagnostic purposes. I also consent to Peek a Boo Baby LLC., allowing this business to use any
images and/or video obtained during the 4D ultrasound scan to be posted on all social media and affiliated websites.
I agree that Peek a Boo Baby 3D/4D, LLC., its employees, owners, agents, affiliates, Sonographers, (collectively Peek a Boo
Baby 3D/4D, LLC.) have no obligation whatsoever to perform any medical procedure or examination or report or provide
any diagnostic medical diagnosis or medical information during or as a result of the Ultrasound. I agree that I shall rely
solely on my personal healthcare physicians/providers for any medical information related to the Ultrasound and agree
that I shall consult with my physician/provider regarding any medical information that could be obtained, if any, from the
Ultrasound.
I understand that ultrasound technology (sound waves) has been used for over 40 years and there is no current evidence
that ultrasound causes any harm to the fetus or mother, or cause any kind of birth defects, gene>c disorders,
miscarriages, premature labor, bleeding, pregnancy complications, or any other know medical complications to the
mother or fetus (collectively, Pregnancy Complications.) I understand that ultrasound does NOT use x-ray, radiation, or
any other radiation energy. I agree there is a possibility that an unknown birth defect or other abnormality may presently
exist, and that such an existing condition may be observed by my physician/provider or others as a result of the
Ultrasound.
I agree Peek a Boo Baby 3D/4D, LLC. shall have no responsibility to detect, report, or diagnose any defect or
abnormalities observed in the Ultrasound, as Peek a Boo Baby 3D/4D, LLC. is not providing any medical services. I hereby
release and agree to hold harmless from any claims, including emotional, mental, or physical distress, which may arise in
connection with the Ultrasound or information discovered or discoverable from the Ultrasound.
I understand that certain conditions may prevent obtaining clear imaging, including fetal position, placenta covering fetal
face, maternal weight, etc. If it is clear the Ultrasound will not be of good imaging quality due to these defined reasons,
the mother has the option of rescheduling one time, at no charge, a courtesy rescan. If it is clear the client has not
followed the recommended drinking policy as stated on the Peek a Boo Baby 3D4D website and at time of check out, the
client has the option to reschedule for a minimal fee.
FINANCIAL RESPONSIBILITY
Payment for all services provided in connection with the Ultrasound are the sole responsibility of the Client and are due
in full at the time services are rendered. Client agrees that because the Ultrasound is not being provided for medical
purposes, the cost for the service is not covered, billed, or reimbursed by health insurance.
Client Name (Printed)
Client Name (Printed)
Client Physician/Midwife
Date of Service
TRANSVAGINAL ULTRASOUND: A Transvaginal ultrasound session is an option performed with an ultrasound transducer
inserted into the vaginal canal. The probe will be inserted by you, the client, and the sonographer will hold onto the
probe and guide it in with you. Generally, higher resolution images are obtained the closer the ultrasound transducer is
to a structure of interest. You are under no obligation to have this type of ultrasound, and it will only be performed with
your consent. If at any stage during the transvaginal ultrasound, you feel uncomfortable or do not wish to continue,
please let the sonographer know and the session will be terminated immediately. If you have any questions or concerns,
please address the sonographer prior to or during the examination. The transvaginal ultrasound has been explained to
me; I understand the following: The ultrasound transducer will be covered with a non-latex probe cover which will be
inserted into my vagina. The sonographer will move the transducer during the procedure to obtain the required
images. I may request the transvaginal ultrasound to be stopped at any time during the procedure. This ultrasound
session may not always provide better image quality. I consent for the Transvaginal Ultrasound to be performed:
YES (initials)
Client Name (Printed)_________________________________ Signature_____________________________________
PRIVACY
By signing this consent, you are authorizing and consent to Peek a Boo Baby 3D/4D, LLC. obtaining the
Ultrasound for the purposes set forth above. Peek a Boo Baby 3D/4D, LLC. has developed a Notice of Privacy Practices
that provides more detailed information about how, and under what circumstances, we may use and disclose the
Ultrasound. You are encouraged to read the Notice in detail. I hereby authorize Peek a Boo Baby 3D/4D, LLC. to provide,
to disclose, and to release to my physician, healthcare provider, and or healthcare professional, the Ultrasound and any
information which may otherwise be considered private, privileged, protected, or personal health information, and
health information as defined and described in the Health Insurance Portability and Accountability Act of 1996 (Public
Law 104-191, 110 Stat. 2024), the regulations promulgated thereunder (such laws and regulations are collectively
referred to as “HIPPA”) and any other state local laws and rules but acknowledge that Peek a Boo Baby 3D/4D, LLC.
GET IN TOUCH
For Same Day Appointments and / or Gender Reveal Parties
If you are interested in a same day appointment or wanting to book a Gender Reveal Party, please fill out the form below. We will get back with you as soon as we can. Thank you, Team Peek
