Ultrasound Model Application

Thank you for your interest in our program! Provider Practice Essentials is a medical education company that trains Nurse Practitioner and Physician Assistants. We are seeking people who are able to serve as training models for hands-on ultrasound education. Ultrasound is a safe medical diagnostic device that uses sound waves to visualize internal organs. It is non-invasive, and does not involve radiation. As a model, we will be practicing ultrasound technique on your body. This will involve applying gel to your skin and applying an ultrasound probe to your skin. The gel is not harmless, and will not stain your clothing, You will be expected to bring comfortable clothing to our program. There will be no nudity required or necessary for this training. If you have known medical conditions that can be seen by ultrasound, we will be visualizing this with our ultrasound machines. We will be discussing diseases, diagnostic findings, and things to identify when performing ultrasound studies. These discussions are not intended to involve your participation, input, or discussion. We do not give medical advice, or diagnostic information to you. By completing this form you agree to hold PPE, its instructors, and other entities harmless for any medical liability of any type, including but not limited to the following: Failure to diagnose a medical condition, failure to identify pathology that is the result of a medical condition, or failure to communicate to you any medical recommendations or clinical guidance. You acknowledge that you are not attending our program to gain medical information, diagnosis, treatment, or referral, and in no way whatsoever expect any clinical management services from us. This program in no way constitutes a physician-patient relationship, provider-patient relationship, or a medical examination. You understand that these services should be provided by your personal physician, and that we do not assume this role in any way whatsoever. In the event we discover a clinical finding on or within your body, we will inform you that you should seek medical care by your personal physician. We will not give you any medical advice related to our findings. You will not infer or assume that any medical advice has been given based on the terms of this agreement. Further, you acknowledge that your participation in our program is voluntary, and will involve compensation. We will be asking you about personal medical information. Your answers to these questions is optional, but requested because it will help us select the correct models for our program. We will protect your personal healthcare information. You will not be asked to give any financial information on this form. Please answer the questions below honestly and accurately.