Client Name: ______________________________________
Date: ______________________________________________
Address: __________________________________________
Phone / Email: _____________________________________
Estimated Weeks of Pregnancy (optional): ______________

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Purpose of the Service

NestView Ultrasound provides a non-medical, keepsake ultrasound experience performed in the comfort of the client’s home. The purpose of this service is to allow families to capture a 2D black-and-white ultrasound image of the fetus and record the fetal heartbeat using a Doppler device as a memorable keepsake.

As part of this service, clients may receive:

• A printed 2D ultrasound image
• A recording of the fetal heartbeat
• A customizable physical photo frame that combines the ultrasound image and the recorded heartbeat

The frame may optionally include the baby’s name or a personalized message, and additional copies may be ordered to share with family members or loved ones.

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Non-Medical Nature of the Service

I understand and acknowledge that:

• NestView Ultrasound is not a medical service.
• The ultrasound session is not intended to diagnose, treat, monitor, or evaluate any medical condition related to the pregnancy or fetus.
• No medical interpretation, medical advice, or clinical assessment will be provided.
• This service does not replace prenatal care or any ultrasound examination performed by a licensed healthcare provider.

I confirm that I am currently receiving prenatal care from a licensed healthcare professional.

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Safety of Ultrasound

Diagnostic ultrasound technology has been widely used in obstetrics for many decades. When used appropriately and for brief periods, ultrasound is considered safe and non-harmful for both the pregnant person and the fetus according to current scientific knowledge.

NestView Ultrasound uses portable ultrasound equipment and Doppler technology solely for keepsake imaging and heartbeat recording, following reasonable safety practices and minimizing exposure time.

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Service Provider Disclosure

The ultrasound session will be performed by:

Daniel Chiantera, an International Medical Graduate (IMG) with extensive training and background in ultrasound from his home country.

I understand and acknowledge that:

• The provider is not currently licensed or regulated as a physician in the Province of Ontario.
• The provider is offering this service only for keepsake purposes, not as a healthcare or diagnostic service.

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Client Acknowledgment

By signing this form, I confirm that:

1. I understand the non-medical nature of this service.
2. I understand that no medical diagnosis or evaluation will be provided.
3. I understand that the service is solely for keepsake and bonding purposes.
4. I voluntarily consent to receiving a 2D keepsake ultrasound image and fetal heartbeat recording.
5. I understand that the photo frame and heartbeat recording are optional keepsake products.
6. I release NestView Ultrasound and the service provider from any liability related to the interpretation or medical use of the ultrasound images or recordings.

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Consent

I have read and understood the information provided above. I have had the opportunity to ask questions and voluntarily agree to participate in the NestView Ultrasound keepsake session.

Client Signature: ______________________________________

Date: _________________________________________________

Service Provider:
Daniel Chiantera
NestView Ultrasound

Signature: ____________________________________________