Advanced Women’s Health Specialists
NIVIN C.S. TODD, M.D., F.A.C.O.G.
1755 Gunbarrel Road, Suite 205 (423) 778-8921 Phone
Chattanooga, Tennessee37421 (423) 778-8922 Fax
Elective Ultrasound Release of Liability
Gender Identification and 3D/4D ultrasounds are not for medical diagnosis or treatment.
The elective ultrasound services provided by Advanced Women’s Health Specialists do not constitute a medical diagnosis, evaluation or treatment and are not intended to substitute or augment a standard diagnostic medical ultrasound.
Since the elective ultrasound service provided by Advanced Women’s Health Specialists is solely for non-medical and non-diagnostic purpose we assume no liability whatsoever for the consequences of any suspected fetal complications and conditions. By purchasing services from Advanced Women’s Health Specialists you agree to release Advanced Women’s Health Specialists, its officers, and employees from all liability arising from the purchased service.
Customers undergoing a 4-D ultrasound at Advanced Women’s Health Specialists must already be receiving treatment or prenatal care from a physician or midwife and they must disclose the name of their provider. Customers must ensure that through their provider they undergo a separate diagnostic ultrasound scan for medical purpose to confirm their due date, to screen for fetal abnormalities and anomalies, and to evaluated any other pregnancy related complications or issues. Provider: ______
Gender identification with ultrasound is never 100% accurate. Our sonographer has many years of OB ultrasound experience and will make every effort to correctly identify gender during your scan. If, for whatever reason, the sonographer determines that gender identification was not possible at the time of your scan you will be rescheduled for a repeat scan at no charge. No refunds or credits will be given.
Advanced Women’s Health Specialists assume no liability whatsoever for the inadvertent and unwanted discloser of the gender of the fetus.
Payment is due prior to the start of the scan. During the ultrasound, the sonographer will exercise his/her best efforts to ensure that suitable images of the fetus are obtained. The patient and or customer acknowledge that, due to circumstances beyond our control, the quality or suitability of the images cannot be guaranteed. These circumstances include, but are not limited to, the position of the fetus, maternal factors, the placenta and the age of the fetus.
At the discretion of the sonographer, if optimal images cannot be obtained at the time of the scan you will be rescheduled for a repeat scan at no charge. No refunds or credits will be given.
I have read and agree to the above terms and conditions of the release form.
Printed name: ______Date: ______
Signature: ______Witness: ______