Simply ask your physician to sign this written permission and call to schedule a session

316-636-9396 (phone)

316-260-1970 (fax)

Patient Name:

Date:

EDC:

Physician Name:

Physician Signature:

Please understand that Baby Waves is a "non-diagnostic" ultrasound service. A Radiologist does not read the exam and your physician does not receive a report. Baby Waves is in no way liable for any abnormalities or complications occurring during your pregnancy. By signing this document, you are waiving any responsibility or liability by Baby Waves or your Physician.

Patient Signature: