Ultrasound Nataly - General Ultrasound Service Waiver

Location: Orlando, Florida

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Patient Acknowledgment and Consent for Ultrasound Services

I, the undersigned patient (or legal guardian if applicable), hereby acknowledge and agree to the following terms regarding the ultrasound services provided by Ultrasound Nataly, located in Orlando, Florida.

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Purpose of Ultrasound

I understand that the ultrasound being performed is for diagnostic imaging purposes only. The ultrasound will provide visual information about the internal structures of my body, but it does not replace a comprehensive medical evaluation by a physician.

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No Medical Diagnosis or Treatment

I acknowledge that while my images will be reviewed by a certified radiologist, Ultrasound Nataly does not provide medical treatment, prescriptions, or definitive diagnoses. The results should be reviewed with my primary care physician or specialist for further evaluation and care.

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No Insurance Billing

I understand that Ultrasound Nataly is a self-pay facility and does not bill health insurance, Medicare, Medicaid, or third-party payers. Payment is due at the time of service, and I am responsible for all fees related to my ultrasound.

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No Guarantee of Results

I acknowledge that ultrasound imaging has limitations, and while every effort is made to capture clear, diagnostic-quality images, certain conditions, body types, or technical factors may limit visibility. I understand that no guarantees are made regarding the completeness or interpretation of the imaging.

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Patient Responsibility

I understand that it is my responsibility to provide accurate information regarding my symptoms, medical history, and any previous imaging studies that may be relevant to this ultrasound.

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Risks and Safety

I understand that ultrasound imaging is considered a safe, non-invasive procedure, but I release Ultrasound Nataly from liability for any unexpected reactions, discomfort, or complications that may arise during or after the ultrasound.

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Pregnancy Disclaimer (For Obstetric Ultrasounds)

If the ultrasound is performed for pregnancy monitoring, I acknowledge that the ultrasound is not a substitute for regular prenatal care. Any concerns regarding my pregnancy should be discussed with my OB-GYN or midwife.

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Cancellation and Refund Policy

I have been informed of the cancellation and refund policy, and I understand that missed appointments or late cancellations may result in fees or non-refundable charges.

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Confidentiality and Privacy

I understand that my health information will be handled in accordance with HIPAA regulations, and my records will only be shared with myself and my designated healthcare provider upon my written request.

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Consent to Imaging and Report Delivery

I consent to the performance of the ultrasound and to receiving my results electronically (via email) or in print. I understand that my results will be ready 72 hours after the scan.

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Acknowledgment and Signature

By signing this waiver, I acknowledge that I have read, understood, and agree to the terms outlined above. I also confirm that I have had the opportunity to ask questions, and that all my questions have been answered to my satisfaction.