Date (MM/DD/YYYY):
Your Name:
Your Date of birth (MM/DD/YYYY):
Spouse/Partner Name:
Address:
Phone:
Email:
How did you hear about us? (choose one): A friendGoogle searchFacebookInstagramPinterestOther
If you found us through a search (like Google) can you tell what search terms you used to find us?
May we use any/all images obtained during your appointment for advertising purposes? YesNo
Doctor Name:
Doctor Phone:
Any problems/concerns about your pregnancy?
What is your due date? (MM/DD/YYYY)
Are you having twins or more? YesNo

Wonder Time LLC offers elective 2D/3D/4D/HD prenatal ultrasound for an entertainment keepsake and to provide a positive bonding experience for mother, family members, and friends with the unborn child. This entertainment ultrasound session will not provide any assumptions, diagnosis, or medical input of any kind and is not intended to take the place of a diagnostic ultrasound or any other medical procedure(s) recommended by your physician or health care provider. I acknowledge the following:

1. I am under the care of a physician or health care provider for the medical diagnosis, input, and recommendations relating to my pregnancy. My health care provider ultimately will confirm my due date, screen for fetal abnormalities, and/or any abnormalities related to my pregnancy.

2. I certify that I am obtaining this 2D/3D/4D/HD ultrasound for entertainment only and I am not obtaining this ultrasound as a replacement for, or in lieu of, standard medical care.

I affix my signature below to indicate that I have read and understood all of this document.I authorize the above.

As a condition of receiving an entertainment ultrasound from Wonder Time LLC, I hereby acknowledge, understand, and agree to the following statements:

• This ultrasound is an elective, non-medical procedure that I have voluntarily requested.

• The sonographer performing the ultrasound is not a doctor or nurse and cannot interpret diagnostic medical conditions, or otherwise offer medical conclusions regarding the images. I understand that the obtained images will not be reviewed by a radiologist or physician. I agree that I have no right of recourse against Wonder Time LLC or my physician for any medical malpractice, professional negligence or medically related claims arising out of the use of this keepsake service.

• The ultrasound session(s) is intended for entertainment purposes only to view fetal movements. The sonographer will make no attempt to provide a medically inclusive ultrasound or confirm fetal well-being.

• I understand that if any incidental findings of any abnormality occur during my ultrasound session at Wonder Time LLC, that the sonographer will inform my doctor’s office via telephone.

• I understand that I am responsible for contacting my health care provider if any questions arise concerning any issues relating to this ultrasound session or any aspect of my pregnancy.

• I give Wonder Time LLC permission to post and/or use any media in the form of still images or moving images for advertising purposes. I understand no names will be posted or released in association with these images or videos.

• I give Wonder Time LLC permission to contact me with marketing promotions, upcoming event information, and contest information using the contact information I’ve provided.

• I realize and understand the quality of my ultrasound images depends upon many factors including body habitus, developmental stage, fetal position, and adequate fluid. I understand Wonder Time LLC does not guarantee the quality of the images or the ability to visualize any characteristics of the fetus such as gender and all images are not stored by Wonder Time LLC. I further understand that factors beyond Wonder Time LLC’s control may also affect the ability to accurately determine the gender of the fetus. I understand that the guarantee of determination of gender is only a monetary reimbursement of the price of the ultrasound session, with a birth certificate required as proof of gender.

• I further understand that while ultrasound is believed to have no harmful or adverse effects on the mother or the fetus, further research or other information may disclose harmful or adverse effects that are presently unknown.

• In consideration of the services rendered, I agree to release and hold harmless Wonder Time LLC and its agents and employees (all referred to as the “released parties”), from any and all claims or causes of action for injury, harm, loss, damage, or other liability, whether caused by the negligence of the released parties or otherwise that result from or are alleged to have resulted from, this ultrasound. In addition, I agree to release and hold harmless the released parties from any and all claims or causes of action for injury, harm, loss, damage, or other liability which results from, or are alleged to result from, the failure of the released parties to accurately determine fetal gender or any other characteristics of the fetus. I will indemnify Wonder Time LLC with respect to any complaint and will agree to arbitration in the state of New Jersey if any disagreements occur.

I affix my signature below to indicate that I have read and understood all of this document.
I authorize the above field to act as my digital signature.