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Belly ImageLIABILITY WAIVER AND RELEASEThe undersigned, acknowledges and agrees that these ultrasound services and imaging are not medical procedures and are not offered as a medical treatment or diagnosis in any manner. Further, the ultrasound services and imaging are not for the purposes of determining or to be used in the future to determine the health status of the fetus(es) and the undersigned mother or the well being of the undersigned mother or fetus(es) at this time, during the pregnancy or at the birth of the fetus(es).Further, the undersigned acknowledges and agrees that the ultrasound services and images are for entertainment purposes only and are not to be used at any time for the purposes of any medical diagnosis, treatment or care of the fetus(es) or mother. The undersigned mother further declares that she is under the care of a qualified physician regarding her pregnancy at the time of the ultrasound services and imaging.The undersigned agrees and acknowledges that under no conditions will Belly Image, its staff, agents or employees be held liable or accountable for any consequences of any known or unknown medical condition of the mother and the fetus(es) or for failure to diagnose, treat or inform said undersigned of any known or unknown medical conditions, risks or problems regarding the undersigned mother and fetus(es).Further, the undersigned agrees and acknowledges that no guarantee can be made or has been made at the time of the imaging as to the picture or video quality and/or content of the imaging due to circumstances beyond the control of Belly Image, its staff, agents and employees, including, but not limited to the position of the fetus(es), position of the placenta or position of the internal organs of the mother. Under no circumstances will Belly Image, its employees, agents or staff be held liable for any injury or damages that may occur to undersigned or of the fetus(es) as a result of any ultrasounds performed on the undersigned mother by Belly Image, its employees, agents or staff.By signing this document, the undersigned releases, acquits, holds harmless and forever discharges Belly Image, its staff, agents and employees from any and all matters of foreseen or unforeseen claims, demands, damages, actions, or causes of actions by the undersigned individually and/or on the behalf of the fetus(es), resulting from any ultrasound imaging performed at Belly Image.In signing this document I certify that I have carefully read and understand this liability waiver and release.Signature DateEmail Address_____________________________Can we post your 3d/4d pictures to our Facebook? ___Yes ___NoStreetMailing Address CityZip CodeStatePhoneDoctor’s NameDoctor’s AddressDoctor’s Phone Number ................
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