Register to Confirm Your Appointment

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Registration Form

Expecting Mother's First Name *First Name as it appears on the ID

Expecting Mother's Middle NameMiddle Name as it appears on the ID

Expecting Mother's Last Name *First Last as it appears on the ID

Email Address *

Cell Phone *Provide a valid cell phone number, numbers only0 / 10

Appointment Details

Package Selection *Select the package you had scheduled

Date of Your Appointment *Provide the Date of Your Appointment

Card Holder's Payment Details

Card Holder's Full Name *

Card Holder's Email Address *

Card Holder's Phone *Provide a valid cell phone number, numbers only0 / 10

Credit Card Billing Details

This is NOT for payment but rather fraud prevention to confirm you are an authorized user of the card that was used to book your appointment. Details MUST MATCH.

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Last 4 Digits of CC Used *This MUST match the card used when booking your appointment.

CC Expiration *This MUST match the card used when booking your appointment.0 / 4

CVV *This MUST match the card used when booking your appointment.0 / 4

Consent *

Prenatal Ultrasounds understands the importance of proper prenatal medical care for both the expectant mother and the fetus. Therefore, in order to provide our patients with an appropriate, meaningful ultrasound screening, Prenatal Ultrasounds requires that you: (i) certify that you are under the care of a physician or other health care provider, and that you are not obtaining this ultrasound as a replacement for, or in lieu of, standard prenatal medical care; and (ii) notify your current physician or health care provider regarding the ultrasound you receive from Prenatal Ultrasounds. In the event you are unable to notify your physician or healthcare provider prior to performance of the ultrasound, you assume sole responsibility for the performance of the ultrasound, you assume the sole responsibility for notifying him/her as soon as practicable following the performance of the ultrasound.

As a further condition to receiving ultrasound services from Prenatal Impressions, you hereby acknowledge, understand and agree to the following statements:

- You agree to receive communication via SMS/Text message regarding your appointment.

– This ultrasound: (i) is an elective procedure that I have voluntarily requested, and (ii) is not intended to take the place of a diagnostic ultrasound or any other test or treatment that has been or may be recommended by your healthcare provider.

– Because of its elective nature, this ultrasound is generally not covered by insurance. Therefore, an advance payment is required.

– The technician who performs this ultrasound, while qualified to provide such ultrasound services, is not a doctor, nurse or healthcare provider, and cannot interpret, diagnose medical conditions from, or otherwise offer medical conclusions regarding the images produced.

– As used by Prenatal Ultrasounds, this ultrasound is intended to provide enhanced images for the purpose of viewing fetal movement in utero. The technician will make no attempt to guarantee a medically inclusive ultrasound or fetal well-being.

– Any images taken by Prenatal Ultrasounds for you, the client, whether photographic or videographic, maybe used by Prenatal Ultrasound at its discretion for any purpose, including but not limited to marketing materials, websites or the like.

– You understand that you are responsible for contacting your own healthcare provider if you have any questions concerning this ultrasound or any other aspect of your pregnancy.

– You agree that the information you have provided within your registration form may be provided to third parties who may provide you with information via email or send you promotional products and/or gifts that may include but are not limited toTarget, Amazon, Mead Johnson (Enfamil), Abbott Nutrition (Similac), Viacord, Pampers, Huggies, A Pea in the Pod, Motherhood and Google.

– You understand that the quality of the ultrasound and the images/videos depends upon many factors, including body tissue content, developmental stage, and fetal position. You understand that Prenatal Ultrasounds do not guarantee the quality of the videotape or the ability to visualize any characteristics of the fetus.

– Video recording and photography during the ultrasound session is prohibited without the expressed written permission of Prenatal Ultrasounds AND it’s employees. Any video and/or photography recorded by guest(s) may not be used in any manner without written permission of Prenatal Ultrasounds AND it’s employees. Materials including, but not limited to the video recording, ultrasound images and any other materials provided by Prenatal Ultrasounds may not be shown or disclosed to our competitors.

As evidenced by your digital acknowledgement via the checkbox and by submitting payment upon scheduling your appointment, you understand that factors beyond Prenatal Ultrasounds' control may also affect the ability to accurately determine the gender of the fetus, and that Prenatal Ultrasounds can provide no warranty or guaranty the best images as the quality is contingent on a variety of factors which include, but are not limited to the baby's position, placement of the placement, amniotic fluid levels. You further understand that while ultrasound is believed to have no harmful effect on the mother or the fetus, future research or other information may disclose harmful or adverse effects that are presently unknown.

IN CONSIDERATION OF THE SERVICES RENDERED, YOU AGREE TO RELEASE SOM AND COMPANY, LLC DBA AS PRENATAL ULTRASOUNDS, ITS PARTNERS AGENTS, AFFILIATES, DIRECTORS, AND EMPLOYEES FROM ANY AND ALL CLAIMS OR CAUSES OF ACTIONS FOR INJURY, HARM, DAMAGE OR OTHER LIABILITY WHICH RESULTS FROM, OR ARE ALLEGED TO HAVE RESULTED FROM, THIS ULTRASOUND, INCLUDING, BUT NOT LIMITED TO, THE FAILURE OF PRENATAL ULTRASOUNDS TO ACCURATELY DETERMINE FETAL GENDER OR OTHER CHARACTERISTICS, AND ANY DAMAGES OR INJURIES RESULTING FROM ULTRASOUND WHICH ARE NOT NOW KNOWN TO OCCUR.

I have fully read this document and I acknowledge that I fully understand and agree to its contents, including that once services are rendered, there are no refunds.

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