Scope of Services
I understand that UltraVision Imaging provides mobile diagnostic ultrasound examinations performed by a trained, credentialed sonographer. Services are limited to ultrasound imaging only and do not include diagnosis, treatment, or medical advice.
I understand that a handheld transducer and water-based gel will be used to obtain images of the ordered anatomy. Some exams (such as pelvic or first trimester OB) may include a transvaginal approach, which will be explained and verbally consented to before proceeding.
I understand that for obstetric exams, fetal anatomy surveys detect approximately 40–60% of structural anomalies. Some conditions may not be detectable at any gestational age. Chromosomal conditions such as Down syndrome are not detectable by ultrasound alone.
Results & Follow-Up
I understand that all images are reviewed and interpreted by a board-certified radiologist. A written report will be sent to my referring physician. Results are not provided by the sonographer at the time of the exam.
I understand that ultrasound is a screening or diagnostic aid — not a definitive diagnosis. A normal result does not guarantee the absence of disease or abnormality. Additional imaging or testing may be recommended based on findings.
I agree to comply with any recommended follow-up exams, additional imaging, or specialist referrals. I understand that failure to follow up may result in delayed detection or diagnosis.
In-Home / On-Site Visit
I understand that UltraVision Imaging provides mobile services and that the sonographer will travel to my home, facility, or designated location to perform the examination. I agree to ensure a safe, reasonably private, and accessible space for the exam to be conducted.
I agree to provide accurate and complete medical history, current medications, prior surgeries, known conditions, allergies, and relevant family history. I will follow any preparation instructions provided in advance (e.g., fasting, full bladder, hydration).
Transvaginal Ultrasound Consent
I understand that a transvaginal ultrasound involves insertion of a narrow, specially designed transducer into the vaginal canal to obtain detailed images of the uterus, ovaries, fallopian tubes, cervix, and surrounding structures. This approach is commonly used for pelvic examinations and first trimester obstetric evaluations.
I understand that I may decline the transvaginal approach at any time. A transabdominal-only study will be performed if I decline, with the understanding that visualization may be limited. I may also request a chaperone at any time.
I voluntarily consent to the transvaginal ultrasound examination as described above.
Self-Referral Acknowledgment
I am requesting this examination on my own behalf, without a physician's order. I understand this is a preventive or elective service, not a response to a known clinical condition.
I accept full financial responsibility for this examination. UltraVision Imaging is self-pay only and does not bill insurance. I understand that self-referred exams are typically not covered by insurance.
I will share my written results report with my primary care physician or a qualified healthcare provider for clinical interpretation and any necessary follow-up. I understand that UltraVision Imaging does not provide diagnoses or medical advice.
In the event of a critical finding, UltraVision Imaging will make a reasonable effort to contact me directly. I understand that I am ultimately responsible for timely follow-up with a qualified physician.
Assumption of Risk & Limitation of Liability
I understand that diagnostic and screening ultrasound is non-invasive, does not use ionizing radiation, and has an excellent safety record. Minimal risks include temporary transducer pressure discomfort. I voluntarily assume any risks associated with this examination.
I understand that image quality may be affected by factors outside the sonographer's control, including body habitus, bowel gas, fetal position, or surgical scarring. These limitations may prevent complete evaluation and do not constitute negligence on the part of UltraVision Imaging.
I acknowledge that UltraVision Imaging and its staff shall not be held liable for outcomes resulting from limitations inherent to ultrasound technology, incomplete studies due to patient or anatomical factors, or failure to detect conditions not visible at the time of examination.
Billing
I understand that UltraVision Imaging is a self-pay only practice. They do not bill insurance, Medicare, or Medicaid. Full payment is due at the time of booking. A receipt will be provided which I may submit to my insurance carrier for potential reimbursement at their discretion. UltraVision Imaging makes no guarantee of reimbursement and is not responsible for coordinating claims on my behalf.
Privacy & HIPAA
I understand that UltraVision Imaging maintains my protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA). My information will not be shared without my written authorization except as required by law or for treatment-related purposes (e.g., radiologist interpretation, referring physician report delivery).
Cancellation Policy
I understand that cancellations or reschedules made less than 24 hours before the scheduled appointment may be subject to a cancellation fee. No-shows without notice may be charged the full exam fee. UltraVision Imaging reserves the right to collect this fee prior to scheduling future appointments.
