Patient Service Agreement

Please review this agreement carefully. All sections apply to your appointment regardless of study type.

1. Patient Responsibilities

By scheduling an ultrasound examination with UltraVision Imaging ("UltraVision"), I agree to:

• Provide accurate and complete health information, including current medications, allergies, and relevant medical history.
• Follow all pre-examination preparation instructions (e.g., fasting, full bladder, hydration) as provided by UltraVision staff. Failure to follow prep may result in a non-diagnostic study and require rescheduling at my expense.
• Arrive on time for my scheduled appointment, or be available at the agreed location for an in-home visit.
• Notify UltraVision at least 24 hours in advance if I need to reschedule or cancel.
• Understand that ultrasound results will be sent to my referring physician (if applicable) within 3–5 business days, and that I should follow up with them to discuss findings.

2. Assumption of Risk & Limitations of Ultrasound

I understand and acknowledge that:

• Ultrasound is a screening and diagnostic tool that uses sound waves and is generally considered safe with no known harmful effects when performed by qualified personnel.
• No medical test is 100% accurate. Ultrasound may not detect all abnormalities, and findings may require additional testing or imaging modalities (CT, MRI, biopsy) for definitive diagnosis.
• UltraVision sonographers are credentialed and trained, but cannot provide medical diagnoses or treatment recommendations during the exam. All interpretations are performed by a board-certified radiologist.
• In certain conditions (obesity, excessive bowel gas, recent surgery, scar tissue), image quality may be limited, and the study may be incomplete or non-diagnostic.
• If a critical or urgent finding is identified, UltraVision will make reasonable efforts to contact me and/or my referring physician promptly.

⚠ TBD-SERGE: Confirm "critical findings" notification policy — within how many hours, who is contacted first

3. Cancellation, Rescheduling & Refund Policy

Cancellations and rescheduling must be made at least 24 hours before your appointment.

• More than 24 hours notice: Full refund or free reschedule.
• Less than 24 hours notice: 50% cancellation fee. Remaining balance refunded within 5–7 business days.
• No-show (missed appointment without notice): No refund. A new appointment requires full payment.
• In-home visits — patient not available at scheduled location: No refund; travel fee forfeited.
• UltraVision-initiated cancellation (equipment issue, weather, sonographer illness): Full refund OR free reschedule at your choice.

Refunds are processed to the original payment method within 5–7 business days. To cancel or reschedule, contact us at (916) 751-1944 or info@ultravisionimaging.com.

⚠ TBD-SERGE: Confirm 50% cancellation fee — is this final, or should it be a flat $50/$75?

4. HIPAA Notice of Privacy Practices — Acknowledgment

UltraVision Imaging is committed to protecting your health information under the Health Insurance Portability and Accountability Act (HIPAA). By signing this agreement, I acknowledge that:

• I have been given the opportunity to review UltraVision's full Notice of Privacy Practices.
• UltraVision may use and disclose my Protected Health Information (PHI) for treatment, payment, and healthcare operations as permitted by law.
• UltraVision will share ultrasound results and report with my referring physician (if applicable).
• I have the right to request restrictions on uses and disclosures of my PHI, and to request a copy of my records.
• UltraVision will not sell my PHI or use it for marketing without my explicit written authorization.
• In case of a data breach affecting my PHI, I will be notified in accordance with HIPAA Breach Notification Rule (within 60 days).

For questions about your privacy rights, contact our Privacy Officer at info@ultravisionimaging.com.

⚠ TBD-LEGAL: Full HIPAA Notice of Privacy Practices document needs to exist at /privacy-policy/ — currently placeholder

⚠ TBD-SERGE: Designated HIPAA Privacy Officer — name + email?

5. Communications Consent

I authorize UltraVision to contact me regarding my appointment, results, and follow-up care via:

• Phone calls to the number I provided
• SMS/text messages (appointment reminders, results-ready notifications) — message and data rates may apply
• Email to the address I provided

I understand I may opt out of SMS messages by replying STOP, or opt out of marketing emails using the unsubscribe link. Transactional messages (appointment confirmations, results) cannot be opted out of while I am an active patient.

6. Financial Responsibility

• UltraVision is a cash-pay (self-pay) service. We do not bill insurance directly.
• Full payment is required at the time of booking via secure online payment (Stripe).
• I may request an itemized receipt to submit to my insurance, HSA, or FSA for potential reimbursement, but UltraVision makes no guarantee of coverage.
• Travel fees for in-home visits are non-refundable once the sonographer has been dispatched.
• I understand that this fee is for the ultrasound technical service only and does not include radiologist interpretation fees if billed separately.

⚠ TBD-SERGE: Is radiologist interpretation included in the listed price, or billed separately? Confirm exact financial model

Electronic Signature

By typing your full legal name below, you are creating a legally binding electronic signature under the U.S. Electronic Signatures in Global and National Commerce Act (ESIGN). Your signature has the same legal effect as a handwritten signature.

Next step: After signing, you will proceed to the Informed Consent specific to your study type. A copy of this agreement will be emailed to you and stored securely in our system.

Informed Consent

Please review the consent specific to your appointment type and sign below.

Diagnostic Ultrasound — Informed Consent

Purpose of Examination

A diagnostic ultrasound is being performed at the request of my referring physician to evaluate a specific medical condition or symptom. The exam uses high-frequency sound waves to produce real-time images of internal structures.

Procedure Description

A trained sonographer will apply water-based gel to the area being examined and move a handheld transducer across the skin. The procedure is non-invasive, painless, and typically takes 20–60 minutes depending on the study type.

Benefits

• No ionizing radiation (unlike X-ray or CT)
• Real-time imaging of soft tissues, organs, and blood flow
• Helps diagnose or rule out medical conditions
• Results sent to referring physician within 3–5 business days

Risks & Limitations

• Ultrasound has no known harmful biological effects at diagnostic levels
• Image quality may be limited by body habitus, bowel gas, or scar tissue
• Ultrasound cannot detect all abnormalities — additional imaging (CT, MRI, biopsy) may be required for definitive diagnosis
• The exam is interpreted by a board-certified radiologist; preliminary observations by the sonographer are NOT a diagnosis

I understand that I have the right to refuse this examination at any time, and I have had the opportunity to ask questions about the procedure.

⚠ TBD-LEGAL: Full diagnostic consent text requires attorney review and Serge approval

Preventive Screening Ultrasound — Informed Consent

Purpose of Screening

A preventive screening ultrasound is a wellness exam performed without a physician referral for the purpose of early detection of certain conditions in patients who currently have no symptoms.

Important Limitations of Screening

• This is NOT a diagnostic exam. A normal screening result does not mean you are free of all disease.
• This exam does not replace regular visits to your primary care physician.
• Screening ultrasound has limitations and may not detect early-stage or small abnormalities.
• If an abnormal finding is detected, you will be advised to follow up with a physician for further evaluation, which may include diagnostic imaging, lab work, or biopsy.
• UltraVision Imaging does not provide treatment or diagnosis — only imaging and radiologist interpretation.

What to Expect

A trained sonographer will perform the exam using a handheld transducer and water-based gel. The procedure is non-invasive and painless. Results will be reviewed by a board-certified radiologist, and a written report will be provided to you within 3–5 business days.

Acknowledgment of Self-Referral

I understand that I am electing to undergo this screening exam without a physician's order. I am responsible for sharing the results with my primary care provider and for following up on any abnormal findings.

⚠ TBD-LEGAL: Screening consent is a new document — requires full attorney drafting and Serge approval. This is placeholder text only.

⚠ TBD-SERGE: Confirm which studies qualify as "screening" — currently assuming Carotid, CIMT, AAA, Breast, Thyroid, Pelvic, Liver/Gallbladder

Obstetric (OB) Ultrasound — Informed Consent

Purpose of OB Ultrasound

An obstetric (OB) ultrasound uses sound waves to evaluate the developing fetus, placenta, amniotic fluid, and maternal pelvic structures during pregnancy. The exam may be performed transabdominally and/or transvaginally depending on gestational age and clinical needs.

What an OB Ultrasound Can Evaluate

• Fetal heartbeat, position, and gestational age
• Number of fetuses (single vs. multiple gestation)
• Fetal growth and anatomy (depending on trimester)
• Placental location and amniotic fluid volume
• Some — but not all — fetal abnormalities

Important Limitations

• OB ultrasound cannot detect all fetal abnormalities. Some conditions (genetic, chromosomal, metabolic, or developmental) are not visible on ultrasound.
• A normal ultrasound does NOT guarantee a normal pregnancy outcome or a healthy baby.
• Image quality may be limited by maternal body habitus, fetal position, low amniotic fluid, or gestational age.
• Fetal sex determination is not 100% accurate and is offered for informational purposes only.
• This exam is NOT a substitute for prenatal care with an OB/GYN provider.

Safety

Diagnostic ultrasound has been used in pregnancy for over 50 years and has no known harmful effects on the mother or fetus when used at diagnostic levels by trained personnel. UltraVision follows the ALARA principle (As Low As Reasonably Achievable) for exposure.

Acknowledgment

I understand the purpose, benefits, and limitations of this OB ultrasound examination. I have had the opportunity to ask questions, and I voluntarily consent to the procedure.

⚠ TBD-LEGAL: Full OB consent requires attorney review and Serge approval

Transvaginal Ultrasound Consent

Your scheduled study (Pelvic Complete TA + TV) includes a transvaginal ultrasound, in which a slim, lubricated probe (covered with a single-use sterile sheath) is gently inserted into the vagina to provide higher-resolution images of the uterus, ovaries, and surrounding pelvic structures.

Why this is needed

A transabdominal pelvic ultrasound alone may not provide adequate detail. The transvaginal approach allows clearer evaluation of pelvic anatomy, especially in patients with bowel gas obstruction or non-distended bladder.

Your rights

• You may decline the transvaginal portion at any time — even after starting. The exam may be incomplete as a result.
• You may request a female sonographer in advance (subject to availability) by calling (916) 751-1944.
• You may request to have a chaperone (family member, friend, or staff member) present during the exam.
• The probe is covered with a new, single-use, sterile sheath for every patient.
• Mild discomfort is possible but the procedure is generally well-tolerated.

By signing below, I voluntarily consent to the transvaginal ultrasound portion of my examination.

⚠ TBD-LEGAL: Transvaginal consent — attorney review required

In-Home Visit Acknowledgment

You have selected an in-home mobile ultrasound visit. Please acknowledge the following:

• I will provide a private, clean, well-lit room with space for portable ultrasound equipment and a flat surface (bed, exam table, or sofa) where I can lie down.
• I will ensure any pets are secured in another room for the duration of the visit.
• I understand the sonographer travels with portable equipment that may have limitations compared to a clinic-based machine. If image quality is inadequate, the sonographer may recommend rescheduling at a clinic location.
• I understand that arrival time is approximate (±30 minutes) due to travel conditions.
• I agree that the travel fee is non-refundable once the sonographer has been dispatched, even if I am not available at the scheduled location.
• I will provide accurate access instructions (gate codes, parking, building entry) at the time of booking.
• For safety, the sonographer reserves the right to decline the visit on arrival if the environment is unsafe, unsanitary, or if the patient is incapacitated and no responsible adult is present.

By signing below, I acknowledge and accept the terms of the in-home ultrasound visit.

⚠ TBD-LEGAL: In-home acknowledgment — attorney review required

Electronic Signature

By typing your full legal name below, you are creating a legally binding electronic signature under the U.S. Electronic Signatures in Global and National Commerce Act (ESIGN). Your signature has the same legal effect as a handwritten signature and applies to all consent sections shown above.

Next step: After submitting, you will be redirected to secure payment via Stripe, then to appointment scheduling via Calendly.

A copy of your completed forms will be emailed to you and stored securely in our HIPAA-compliant system.