Piezoelectric materials have been vastly used in ultrasonic transducers for medical imaging. In this paper, firstly, the most promising lead-free compositions with perovskite structure for medical imaging applications have been reviewed. The electromechanical properties of various lead-free ceramics, composites, and single crystals based on barium titanate, bismuth sodium titanate, potassium sodium niobate, and lithium niobate are presented. Then, fundamental principles and design considerations of ultrasonic transducers are briefly described. Finally, recent developments in lead-free ultrasonic probes are discussed and their acoustic performance is compared to lead-based transducers. Focused transducers with different beam focusing methods such as lens focusing and mechanical shaping are explained. Additionally, acoustic characteristics of lead-free probes including the pulse-echo results as well as their imaging capabilities for various applications such as phantom imaging, in vitro intravascular ultrasound imaging of swine aorta, and in vivo or ex vivo imaging of human eyes and skin are reviewed.