First Name *

Last Name *

Email *

Phone *

Date of birth *

Address *

City *

State *

Zip code *

Physician/OB/Gyn Office: *

First day of your last menstrual cycle:

Estimated Due Date (if known):

How did you hear about Nurture?

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. *Please Initial

Because of its elective nature, this ultrasound is a self-pay service. Therefore, advance payment is required at time of scheduling. *Please Initial

You fully acknowledge that Nurture does not issue refunds and payment, in full, is due before the time of your initial visit. *Please Initial

The Sonographer who performs this ultrasound, while registered and qualified to provide such ultrasound services, is not a physician, and does not interpret, diagnose medical conditions from, or otherwise offer medical conclusions regarding the images produced. *Please Initial

As used by Nurture, this ultrasound is intended to provide enhanced images for the purpose of viewing fetal movement in utero. The Sonographer will make no attempt to guarantee a medically inclusive ultrasound or fetal well-being. *Please Initial

You understand that you are responsible for contacting your own healthcare provider if you have any questions concerning this ultrasound or any other aspect of your pregnancy. *Please Initial

You understand that the quality of the ultrasound and the images/video depends upon many factors including body tissue content, developmental stage, and fetal position. You understand that Nurture does not guarantee the quality of the images/video of the ability to visualize any characteristics of the fetus. *Please Initial

You acknowledge that Nurture may offer a return visit (free of charge) only at the discretion of the Sonographer administering the scan. Return visits are only offered if the Sonographer feels that the ultrasound was not of reasonable or satisfactory quality according to the above statement. *Please Initial

You give FMCC and HFBC permission to anonymously use your images/videos for social media and marketing purposes. All identifying information will be removed. *Please Initial

Client Signature: *

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I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.