Provider Acknowledgement Form

Healthcare Provider  

Your patient has requested an ELECTIVE prenatal 2D or 4D ultrasound at Baby Views, LLC.  We provide limited, diagnositc ultrasound sessions to promote prenatal parental bonding before birth that often creates healthier lifestyles.  Our service will reduce the many "reassurance scans" provided in our healthcare offices today.  We require all clients to provide proof of ongoing prenatal healthcare.  Our sessions do not replace regular prenatal care or diagnostic exams ordered by a client's healthcare provider.  

I acknowledge my patient, ________________________________________ is currently receiving ongoing prenatal care with my office.  Her EDC is_______________________.  I have not ordered this ultrasound session nor will I be supervising or interpreting this ultrasound.

____________  this patient has undergone a diagnostic ultrasound exam.

____________ this patient has NOT undergone a diagnostic ultrasound exam.

I understand while this is a limited, diagnostic exam, the possibility exists that the ARDMS certified sonographer at Baby Views may incidentally discover issues of diagnostic value;  upon which, I request to be contacted regarding any such concerns.

 Print Provider Name:_______________________________      Date:_______________________________

Provider Signature: _________________________________     Telephone/Fax:_______________________

 Patient/Prospective Client

I authorize the above named healthcare provider and staff to release the requested information to Baby Views.  I also give permission to Baby Views to communicate to my provider listed above any incidentally discovered areas of concern that may be of diagnostic value.  I understand that this is an elective procedure only;  and as such, I agree not to hold either party listed herein responsible or liable for diagnosisng any current or future potential health concerns relating to my pregnancy or unborn baby.

Print Patient Name:_________________________________     Date:________________________________

 Patient Signature:___________________________________

Baby Views 

 12921 Cantrell Rd., #300

Little Rock, AR  72223

Phone (501)907-6464  Fax (501) 421-0182