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SOCIETY OF POINT OF CARE ULTRASOUND EDUCATION VOLUNTEER CONSENT

You are volunteering to participate as a model for learners to perform point of care ultrasound on your body. Ultrasound is a medical procedure that uses high frequency sound waves to produce images of the human body. This consent form provides you information about the procedure to help you decide whether you would like to participate. Please read this form, and ask any questions you have before agreeing to be a volunteer model.

The purpose of the ultrasound procedure to be performed on you is to better educate learners in the use of ultrasound. The purpose of this ultrasound procedure is not to provide medical care or diagnose medical conditions. There are no risks/ side effects of participating as a volunteer model. Your participation benefits the medical society in helping learners acquire and practice ultrasound skills.

In the event that the scanning individual(s) believe they have found an abnormality, they will advise you to speak with your primary care clinician. The purpose of this ultrasound event is for educational purposes and non-diagnostic. Therefore, scans today are not to provide medical care nor to look for any abnormalities, so it is possible that abnormalities/medical conditions may not be detected. The faculty, students, or any other entities of today's event, including SPOCUS, are not responsible for any outcomes involved with the ultrasound procedure. If you suspect that you have a medical disease or condition that needs diagnosis, we encourage you to follow up with your primary care clinician or local student health office. Since this is an educational activity and not a healthcare procedure, HIPPA laws are not applicable.

Efforts will be made to keep your personal information confidential. We cannot guarantee absolute confidentiality. Your personal information may be disclosed if required by law. While we are not planning on saving sonographic images from today's event, in the event that they are, every attempt at anonymity will be made, although demographic content may be recorded as well.

VOLUNTEER CONSENT

I agree to participate as a volunteer to be scanned by students and other learners in an educational setting during iScan, where students are acquiring skills in conducting ultrasound. I recognize that by participating in this activity, no medical care is being provided and the interpretations of ultrasound imaging in either finding abnormal conditions, or not finding abnormal conditions, should not be considered factual and/or a medical diagnosis in any way. I understand that the ultrasound procedure performed on me is purely for educational purposes to teach learners the skills of conducting point of care ultrasound. The purpose of the ultrasound procedure is not to locate or diagnose medical conditions.

In consideration of all of the above, I agree to volunteer as a model for an ultrasound scan. 

Today's Date: December 22, 2024

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email
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Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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