Waiver and Release Please enable JavaScript in your browser to complete this form.Your Information - Step 1 of 4Today's DateDate Of BirthDue DateName *FirstLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *PhoneNextHow Did You Find Out About Us?WebsiteFacebookGoogleOtherReferred By SomeonePlease Explain WhereWho Referred You?NextOB/GYN NameOB/GYN AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeClinic NameNext I understand that this ultrasound service is nondiagnostic and does not take the place of a medical ultrasound. I understand that I am purchasing images, imaging services, and products from Look At Me 4DImaging for entertainment purposes only. Look At Me 4D Imaging is not a licensed medicalprofessional and is not providing any medical care. I agree I have no right to recourse againstLook At Me 4D Imaging in any medical malpractice, professional negligence, or any medicalclaim related to my pregnancy or the birth of my child, including error in sex determination.I am currently receiving care from a health care professional. I acknowledge the images created by Look At Me 4D Imaging have little or no diagnostic value.I understand no diagnosis will be made during this ultrasound. If I have any concerns about mypregnancy, I will not rely on Look At Me 4D Imaging for any medical advice. I understand there is an inherent risk in any activity while pregnant including this ultrasoundsession. I acknowledge it is my responsibility to inform myself of these risks before pursuingthese ultrasound services. I assume all risk of harm or injury to me or my fetus resulting from theservices provided by Look At Me 4D Imaging. I hereby release and forever discharge Look At Me 4D Imaging and their employees from allliability, claims, and demands, actions and causes of action, and other actions and liabilities, ofany nature whatsoever, that I or my baby have to arise out of or in any way related to my visit toLook At Me 4D Imaging. I agree that I have no right to file any lawsuit or institute any otheraction or legal proceedings of any type arising out of or in any way related to my visit to Look AtMe 4D Imaging. As defined in this document, Look At Me 4D Imaging shall include its owners,officers, agents, employees, attorneys, and affiliated related entities. I understand this waiver and release is a binding legal document that affects my legal rights.This document also binds my spouse, children, heirs, representatives, distributes, guardians,and assigns. I acknowledge, in rare circumstances, Look At Me 4D Imaging may wish to contact my medicalcare provider. I give my permission for Look At Me 4D Imaging to contact my medical provider Ilisted on this form. I give Look At Me 4D Imaging permission to reproduce, post, or use any images or recordeddata, without further compensation, for advertisement and promotional purposes. I am aware and prepared for certain circumstances that may prevent Look At Me 4D Imagingfrom obtaining quality Images. These circumstances may include any one or combination of thefollowing: fetal position, amniotic fluid, location of the placenta, location of extremities, maternalobesity. If the Look At Me 4D Imaging ultrasound technologist is not satisfied with thecooperation of the baby and the images obtained, Look At Me 4D Imaging may offer a freerepeat session. By signing I acknowledge that I have read and I understand all of the above. SignatureClear SignatureSubmit