ULTRASOUND CONSENT FORM
An ultrasound has been ordered on you and your unborn child by your physician.
There are many reasons that this diagnostic test may have been ordered. Some of
these include: Evaluation of your baby for birth defects, growth patterns, amniotic fl uid
level, Doppler fl ow indices, abnormal blood test results, or as adjuncts to diagnostic/
therapeutic testing or procedures. The quality of ultrasound examinations are
extremely dependent on the equipment utilized, the sonographer doing the ultrasound,
the position of your baby within your womb, your body habitus, previous abdominal
surgery and the physician who interprets your exam.
Ultrasound examinations have never been shown to damage you or your baby. This
is not an x-ray. Ultrasound uses sound waves. The ultrasound produces a small burst
of high frequency sound and then listens for the “echo” of the sound in your body. A
computer then integrates this information to make the picture that you see on the
screen. Many things can be seen about your baby, such as birth defects and growth
abnormalities. Ultrasound is also used to see where the baby is in relation to the
needle when certain invasive procedures are done, such as amniocentesis.
Failure to have this ultrasound done may make it diffi cult, if not impossible, to care for
you and your pregnancy in the best way possible. There may be abnormalities of your
reproductive system that may benefi t from diagnosis and treatment. You may not be
able to take advantage of many options afforded to you by law. The birth of your baby
may be compromised by not being able to have the appropriate specialists present
during your pregnancy and at the time of your delivery that your baby may need.
Without ultrasound, therapeutic measures would also not be possible, and this may
result in a damaged baby or even the loss of the life of your baby.
The utmost care and concern is given to you and your unborn child. Even so,
ultrasound is not a perfect science and things can be missed or not seen depending on
the age of the baby, your body composition, and the position of your baby within the
womb. There are some abnormalities that are never seen with ultrasound.
I understand that ultrasound cannot see all things in me or my unborn child, but that it
may be very helpful tool to help manage my pregnancy and plan the delivery.
I have read this consent, fully understand the above information, have had all my
questions answered to my satisfaction.
__ I want an ultrasound performed on me.
__ I decline to have an ultrasound performed on me.
Signed ______________________________________________________
Date ___________________________________
Witness _____________________________________________________
Date ___________________________________
Southwest Location: 5761 S. Ft. Apache • Las Vegas, Nevada 89148
Summerlin Location: 10105 Banburry Cross, #430 • Las Vegas, Nevada 89144
Green Valley Location: 3001 Horizon Ridge Parkway • Henderson, Nevada 89052
Phone: (702) 341-6610 • Fax: (702) 341-6961 • www.DesertPerinatalAssociates.com
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