Moments Studio Registration Form Full Name * Date of Birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone # * Country (###) ### #### How did you hear about MOMents Studio? * Expected Due Date? * MM DD YYYY Obstetrician (pregnancy doctor) Name and Location: * Obstetrician Phone # * Country (###) ### #### Have you had any problems during your current pregnancy? * If yes, please describe: Have you had an ultrasound during this pregnancy? If yes, how many? * Were the results of the ultrasound(s) normal? * If no, please discribe: Is your doctor aware of your visit today? * * I understand that the information provided above is complete and true to the best of f my knowledge. I understand that this ultrasound is elective and, therefore, is not covered by insurance and must be paid in full prior to time of appointment. I understand that this ultrasound is not diagnostic, and I will not hold MOMents Studio Liable for any fetal or maternal abnormalities discovered prior to or after this ultrasound. Signature * Date * MM DD YYYY
