All clients must review and sign this form prior to appointment. Form will be sent to client along with intake forms.

I hereby authorize Foundations Resource Center to perform an elective, non-diagnostic ultrasound for the purpose of obtaining three-dimensional imaging of my unborn child. I understand and acknowledge that this ultrasound is not a medical procedure, and is not intended to diagnose, treat, or detect any medical or obstetrical conditions, including fetal abnormalities or birth defects.

I further understand that this service is for personal and elective use only, and is not covered by insurance. I acknowledge that I am voluntarily choosing to undergo this ultrasound for bonding and visualization purposes only.

I also understand and acknowledge that I am required to be under the care of a licensed healthcare provider (OB/GYN, midwife, or other qualified physician) for my pregnancy. I further understand that the services provided by Foundations Resource Center do not replace or substitute for medical care, diagnosis, or treatment by a qualified healthcare provider. I agree that I will continue regular prenatal care with my healthcare provider and will direct any medical questions or concerns regarding my pregnancy to them.

I understand that optimal imaging results are not guaranteed and may be affected by various factors beyond the control of Foundations Resource Center, including but not limited to fetal position, placental location, and amniotic fluid levels.  At the discretion of the sonographer, one re-scan opportunity will be provided in the case that optimal images are not able to be obtained during the original appointment.  I understand that a re-scan will not be provided after 32 weeks.

By signing below, I hereby release and hold harmless Foundations Resource Center, its employees, agents, and affiliates from any and all claims, demands, causes of action, or liability of any kind arising from or related to the elective ultrasound service provided.

I certify that I have read and fully understand the information provided in this document. My signature below indicates that I agree to the terms and conditions stated above, and that I am signing this form voluntarily and with full knowledge of its contents.

All clients must review and sign this form prior to appointment. Form will be sent along with intake forms.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights
You have the right to get a copy of your paper or electronic records, correct your paper or electronic records, request confidential communication, ask us to limit the information we share, get a list of those with whom we’ve shared your information, get a copy of this privacy notice, choose someone to act for you, and file a complaint if you believe your privacy rights have been violated.
 
Your Choices
You have some choices in the way that we use and share information as we tell family and friends about your condition, provide disaster relief, provide mental health care, market our services and sell your information, and raise funds
 
Our Uses and Disclosures
We may use and share your information as we serve you, run our organization, bill for your services, help with public health and safety issues, do research, comply with the law, respond to organ and tissue donation requests, work with a medical examiner or funeral director, address workers’ compensation, law enforcement, and other government requests, and respond to lawsuits and legal actions.
 
Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. 
 
Changes to Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request and in our office.