Client Acknowledgement & Waiver Agreement

Full Name*

Address*

City / ZIP*

Phone*

Physician Name*

Physician Phone*

Due Date*

How Did You Hear About Us*

Prenatal Care*
I acknowledge that SWEET PEEK, LLC has informed me of the importance of receiving prenatal care to support a healthy pregnancy. I confirm that I am currently receiving prenatal care from a licensed medical provider, or in the process of establishing care.)I acknowledge that I have been informed by SWEET PEEK, LLC that prenatal care is important to a healthy pregnancy. I am currently receiving prenatal care and OR in the process.

Concerns Should Be Referred to Physician*
I understand that services provided by SWEET PEEK, LLC are elective, non-medical in nature. These services are not a substitute for professional medical care. I agree that any concerns or questions regarding my pregnancy will be directed to my physician or other qualified healthcare provider. Under no circumstances will I rely on SWEET PEEK, LLC or its services for medical advice, diagnosis or treatment. I have also been informed by SWEET PEEK, LLC that use of SWEET PEEK, LLC services cannot substitute for care of a physician. If I have any concerns regarding my pregnancy, I will contact my doctor. I will in no way rely upon SWEET PEEK, LLC or its services for medical advice.

No Professional Negligence Claims*
I understand that the services provided by SWEET PEEK, LLC are elective, non-medical in nature, and intended solely for keepsake purposes. I acknowledge and agree that SWEET PEEK, LLC shall not be held liable for medical malpractice, professional negligence or any medical-related claims associated with my pregnancy or the birth of my child(children). This waiver includes, but is not limited to, any claims arising from or related to gender determination or ultrasound imaging accuracy. I am purchasing SWEET PEEK, LLC services and products for keepsake, non-medical purposes. I agree that I have no right to recourse against SWEET PEEK, LLC in any medical malpractice, professional negligence or any medical related claim arising out of or in any way related to my pregnancy or the birth of my child. This includes any claim for error in gender determination.

Assumption of Risks*
I acknowledge that there is inherent risk in any activity relating to a developing fetus and there are potential risks in this type of activity. I understand SWEET PEEK, LLC follows FDA recommendations for length of scan and frequency of ultrasound sound waves, and that no detrimental effects have been found in 40 years of studies. Nonetheless, I hereby voluntarily assume all risk of harm or injury to me or my unborn child resulting from the services provided by SWEET PEEK, LLC.

Waiver and Release of Claims*
I hereby waive, release, acquit and forever discharge SWEET PEEK, LLC from any and all claims, expenses, demands, costs, causes of action, and other actions and liabilities, of any nature whatsoever, whether known or unknown, whether in law or equity, that I or my baby may have arising out of or in any way related to my visit to SWEET PEEK, LLC. I agree that I shall have no right whatsoever to file any lawsuit or institute any other action or legal proceedings of any type arising out of or in any way related to my visit to SWEET PEEK, LLC.

Photo Release*
I grant SWEET PEEK, LLC permission to post or use any photos or recorded data for advertisement purposes. I understand no names will be posted or used with the photos.

Picture Quality*
I understand that image quality is influenced by various factors. I acknowledge that SWEET PEEK, LLC may not always be able to capture clear images or determine gender during the session. I understand no refunds are available if unable to obtain pictures or gender. I have chosen to obtain an elective 3-D fetal ultrasound from SWEET PEEK, LLC & I understand that this elective 3D ultrasound was not ordered or prescribed by my physician. I understand that this ultrasound is not to be used to replace physician care. I have been informed that SWEET PEEK, LLC follows FDA recommendations for frequency (sound waves) and length of scan which has found no detrimental effects in 40 years of case studies.

I have read and understand ALL the above. I AGREE to all the above.*
Yes, I agree

Signature*

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