Waiver of Liability for MOMents Studio by Ventura Ventures, LLC

MOMents Studio understands the importance of proper prenatal medical care for both the expectant mother and baby. Therefore, in order to provide our patient with an appropriate, meaningful ultrasound session, MOMents Studio asks that you: (i) certify that you are under the care of a physician or other healthcare 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 MOMents Studio.

We request that you present to MOMents Studio an acknowledgement of receipt of this notice, signed by your physician or health provider, prior to performance of the ultrasound. In the event you are unable to notify your physician or health provider prior to performance of the ultrasound, you assume sole responsibility for notifying him or her as soon as practical following performance of the ultrasound. As a further condition to receiving ultrasound services from MOMents Studio, you hereby acknowledge, understand and agree to the following statements:

• 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, 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 or diagnose medical conditions from, or otherwise offer medical conclusions regarding the images produced.

• As used by MOMents Studio, 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.

• You understand that the quality of the ultrasound images and/or recordings, or other audio-visual media, depends upon many factors including body tissue content, developmental stage and fetal position. You understand that MOMents Studio does not guarantee the quality of the images or other audio-visual media, or the ability to visualize any characteristics of the fetus.

• You understand that while we make every effort to capture a good image of your baby, we cannot guarantee the cooperation nor the position of the baby. Sometimes if the baby’s position is face down, i.e., towards maternal spine, it may be difficult to see the baby’s face. In this case, a one-time complimentary rescan can be scheduled at sonographer’s discretion. Every prenatal ultrasound shows different image quality and depends on the gestational age, position, amniotic fluid levels, placental locations, and other varying factors.

• As evidenced by your signature below, you understand that factors beyond our control may also affect the ability to accurately determine the gender or the fetus, and that MOMents Studio can provide no warranty or guarantee as to the accuracy of any such determination. You further understand that while ultrasound is believed to have no harmful effects on the mother or the fetus, future research or other information may disclose harmful or adverse effects that are not presently known.

IN CONSIDERATION OF THE SERVICES RENDERED, YOU AGREE TO RELEASE MOMENTS STUDIO, ITS AGENTS, AFFILITATES, 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 MOMENTS STUDIO ULTRASOUND TO ACCURATELY DETERMINE FETAL GENDER OR OTHER CHARACTERISTICS, AND ANY DAMAGES OR INJURIES RESULTING FROM ULTRASOUND WHICH ARE NOT KNOWN TO OCCUR. 

“I have carefully read this document and by signing at the bottom, acknowledge that I fully understand and agree to the entirety of its contents.”