3D and 4D Ultrasounds in West Houston and Katy Texas - Westside Ultrasound Services
Service Form
Provider's Name:_________________________________________________________________
Your Patient,________________________________________, has requested a non-diagnostic ultrasound at
our 3D/4D facility for the date of,________________________.
Westside Ultrasound Services Prenatal Care Verification Form
Using the latest in 3D/4D fetal imaging, Westside Ultrasound Services allows your patients to view their baby during a relaxed and personalized ultrasound session. We offer a non-diagnostic ultrasound. We do not provide measurements, determination of due dates or other related diagnostic information. Our services are not intended as a replacement for a full diagnostic.
- ARDMS registered sonographers, using the latest technology in accordance with FDA regulations.
- We offer the highest quality in external 4D, 3D and 2D imaging and provide a nurturing atmosphere where fetal cardiac activity, fetal number and gender are verified, if possible.
- Our mission is to give parents a visual closeness and to strengthen their bond with their unborn child.
We require all of our clients to receive prenatal care, and that their healthcare provider be informed, that an elective ultrasound has been requested. If this is not your patient, or you have any questions regarding our services, or you do not want your patient to use our supplemental service, please contact us. This service will be provided at no cost of liability to you or your office.
The patient's healthcare provider will be notified immediately if any problem's are seen during our session or sessions.
I herby authorize my patients request to obtain an elective ultrasound with Westside Ultrasound Services.
_____________________________________________________________________________
Obstetrician/Healthcare Provider's signature
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Westside Ultrasound Services
23920 Katy Freeway, Katy, TX 77450
Phone: 713-825-2701