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In an effort to be make your appointment more enjoyable, please complete the following form prior to your appointment.  Thank you!

Contact Information

Waiver and Release

Prenatal Care:  I acknowledge that I understand my session with A Moment in Time LLC does not supplement a doctor's care.  A Moment in Time LLC does not screen for abnormalities.  The scan you receive will not be reviewed by a physician.  However, in the event there is an obvious abnormality seen, we will notify your doctor.

No Professional Negligence Claims:  I acknowledge that I am purchasing an elective ultrasound through A Moment in Time LLC for keepsake purposes only.  This is a non-medical ultrasound.  I agree that I do not reserve the right to hold A Moment in Time LLC liable for any medical mal-practice, professional negligence or medical-related issue related to my pregnancy and/or birth of my child.  

Photo Release:  I give A Moment in Time LLC my permission to post or use any photos or videos obtained during my session for advertisement purposes.  All identifying information will be removed prior to posting.

Picture Quality:  I understand the quality of the images/video I receive is highly dependent on many factors, including but not limited to, position of baby, fluid around baby and body habitus of mother.  I understand A Moment in Time LLC is not always able to obtain optimal pictures/videos during my session,   I also understand that I am given the option to return with 2 weeks of my appointment for a $65 return visit.

Thank you for submitting!

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