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Ultrasound consent form

Ultrasound consent form 2026

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The document is a consent form for an elective ultrasound procedure conducted by Sneak Peek, LLC. It outlines the purpose of the ultrasound, which is to provide 2D, 3D, or 4D images of the baby for keepsake purposes and gender reveal, rather than for diagnostic reasons. The patient acknowledges that the service is not covered by insurance and confirms they have consulted with their physician prior to the procedure. The form also notes that optimal imaging may vary based on the baby's position or amniotic fluid levels.

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Click ‘Get Form’ to open the ultrasound consent form in the editor.
Begin by reading the introductory section carefully. This outlines the purpose of the ultrasound and confirms that it is not for diagnostic reasons.
In the authorization section, clearly indicate your agreement by signing in the designated area labeled 'Patient Signature'.
Next, print your name in the 'Patient Name (printed)' field to ensure clarity.
Fill in your 'Date of Birth' accurately to verify your identity.
Lastly, have a witness sign in the 'Witness' section to complete the form.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Do you need prior auth for ultrasound?

These procedures will need to be authorized first then scheduled. Ultrasound and diagnostic x-rays do not require prior authorization.

Which diagnostic procedures require a signed consent?

All Diagnostic ultrasounds require a physician script/referral prior to performing exam.

Can I make my own consent form?

Obtaining informed consent in medicine is a process that should include describing the proposed intervention, emphasizing the patients role in decision-making, discussing alternatives to the proposed intervention, discussing the risks and benefits of the proposed intervention, and eliciting the patients preference,

What are the 4 types of consent forms?

Consent form 1 is for adults and those patients having anaesthetic Consent form 2 is for paediatrics Consent form 3 is for procedures without sedation Consent form 4 should be used when the patients lack capacity and should be completed by the professional doing the procedure.

Do you need informed consent for ultrasound?

In almost all cases, written consent is not required for non-interventional ultrasound examinations.

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