Please fill out this intake to be seen by The HG and Morning Sickness Clinic, PC, which is currently operating in Georgia only. Please fill out this intake only if you are a new patient living in Georgia wanting to be seen through telehealth. If you have any questions, please text us at (770) 464-5732.

For the next question, your percentage weight loss is {percentageOf}%. If your percentage is negative, you are gaining weight and your "weight loss over the last 7 days" should be 0%. 

Your HELP score today is {yourHelp}

The HyperEmesis Level Prediction Score was developed by the HER Foundation to quantify HG symptoms into a score that can be trended over time to monitor progress and response to treatment. 

Scores below 20 indicate either no HG (morning sickness) or mild HG.
Scores between 20 - 32 indicate symptoms are in the moderate range.
Scores between 33 - 60 indicate severe symptoms that need aggressive care.

 

The Pregnancy Unique Quantification of Emesis in 24 hours (PUQE-24) Score is another method of measuring HG severity

 

 

Over the last two weeks, how often have you been bothered by any of the following problems?

Over the last two weeks, how often have you been bothered by any of the following problems?

THE HG AND MORNING SICKNESS CLINIC, P.C. (“MSC”) operates as a self-pay medical practice in Georgia and Florida. We do not bill insurance for any services in these states. All services provided in Georgia and Florida are cash-pay and must be paid at the time of service.

 
PAYMENT

Payment is due in full at the time services are rendered. We accept credit cards, debit cards, HSA/FSA cards. We will send you a separate PCI-compliant card on file form to complete after you have completed these intake forms.

The cost of services will be provided to you prior to treatment. Prices may change periodically. Upon request, you may receive a Good Faith Estimate of the total expected charges for non-emergency services, as required by federal law.

 
NO-SHOW AND LATE CANCELLATION POLICY

A no-show fee of up to $50 will be charged if you miss an appointment without 24 hours notice. Arriving more than 20 minutes late may require rescheduling and may incur a late cancellation fee.

 
CARD ON FILE

You authorize The HG and Morning Sickness Clinic to keep a credit card on file to process payments for services, no-show fees, outstanding balances, and charges you approve electronically.

 
BILLING AND COLLECTIONS

Payment is due at time of service. Any unpaid balances may accrue a $15 monthly late fee. Accounts not resolved may be referred to a collection agency, and you agree to pay collection costs and attorney’s fees up to 33% of the balance.

 
FINANCIAL RESPONSIBILITY

I acknowledge and agree that all services provided in Georgia and Florida are self-pay, and I am financially responsible for all charges.

I understand that medical treatment outcomes cannot be guaranteed and no warranty is offered regarding the results of care.

I consent to routine medical care provided by The HG and Morning Sickness Clinic, including evaluation, diagnosis, ordering of tests, prescribing medications, coordination with other clinicians, and any other care deemed medically necessary for my condition. I understand that no guarantees can be made regarding outcomes.

 

RISKS OF HYPEREMESIS GRAVIDARUM
HG may lead to serious complications including dehydration, malnutrition, kidney injury, Wernicke’s encephalopathy, electrolyte abnormalities, and, extremely rarely, maternal death. Pregnancies affected by HG may have higher rates of preterm delivery, fetal growth restriction, placental abruption, preeclampsia, or stillbirth. Children exposed to severe maternal malnutrition may have higher risks of neurodevelopmental and behavioral concerns.

Because HG can pose significant risks to both maternal and fetal health, treatment—including medication management—is often medically necessary to stabilize hydration, nutrition, and overall well-being.

HG can increase the risk of obstetric complications. MSC provides specialty care for nausea and vomiting in pregnancy and does not replace the role of an obstetric provider. I agree to maintain regular prenatal visits with my obstetric provider and to follow their recommendations alongside HG treatment. I understand that failure to stay in routine OB care may increase risks to my pregnancy.
 
MEDICATION MANAGEMENT
We will help manage your symptoms using evidence-based recommendations from the American College of Obstetricians and Gynecologists and the Hyperemesis Education and Research Foundation.

Bonjesta and Diclegis are the only FDA-approved medications for nausea and vomiting in pregnancy; all other medications commonly used for HG—such as ondansetron (Zofran), metoclopramide (Reglan), or promethazine (Phenergan)—are widely used off-label and have established safety profiles.

Your provider will discuss with you the purpose of each medication, how it works, dosage and frequency, expected benefits, potential side effects, drug interactions, and alternatives. You may request copies of relevant medical literature at any time.

RISKS AND BENEFITS OF MEDICATIONS
Medications used to treat HG are intended to reduce nausea and vomiting, improve hydration and nutrition, prevent hospitalizations, decrease risks related to maternal malnutrition, and support healthy fetal growth. Many patients experience substantial improvement with appropriate treatment.

No medication is completely risk-free, and research in pregnancy is limited. For many medications, the full scope of risks is not known. Most medications used for HG have long records of use in pregnancy and generally reassuring safety profiles, but small or rare risks cannot be ruled out.

Ondansetron (Zofran) and related serotonin-blocking medications
Some studies suggest a small possible increase in the risk of cleft lip or cleft palate, while many large studies have not confirmed this association.
There may be a small increased risk of structural cardiac defects; findings across studies are inconsistent and the absolute risk appears low.
Ondansetron can cause QT prolongation, particularly in individuals with electrolyte abnormalities or underlying heart conditions.

Dopaminergic anti-nausea medications (metoclopramide, prochlorperazine, promethazine, droperidol, chlorpromazine)

Rare risk of extrapyramidal symptoms (EPS), including muscle stiffness, restlessness, abnormal movements, or dystonia.
Very rare cases of long-term movement disorders (such as tardive dyskinesia) have been reported, typically with prolonged or high-dose use.
Most EPS symptoms, if they occur, are temporary and treatable.

Steroids
May be used for severe or refractory HG.
There is a small theoretical risk of cleft lip/palate with early-pregnancy steroid exposure, although the absolute risk is very low.

Acid reducers, antihistamines, vitamins, and electrolytes (famotidine, pantoprazole, omeprazole, diphenhydramine, thiamine, vitamin B6, etc.)

Generally have reassuring safety data in pregnancy.
Risks may include allergic reactions, sedation, or electrolyte changes.

IV fluids and IV medications
Risks include allergic reactions, vein irritation, infection, electrolyte disturbances, and very rarely anaphylaxis.

Other medication side effects

Some medications used to treat HG may cause drowsiness or impair alertness. I agree to avoid driving or operating machinery if I feel sedated.

ALTERNATIVES TO MEDICATIONS
Alternatives may include:

Supportive care only (hydration, rest, dietary modifications)
Non-medication therapies (ginger, acupressure, lifestyle strategies)
Behavioral or nutritional support
Choosing to use no medication
Consultation with a high-risk obstetric specialist
However, untreated or undertreated HG carries its own risks—including dehydration, malnutrition, electrolyte abnormalities, hospitalization, and fetal complications—which must be weighed against the risks of medication use.

INFORMED CONSENT
I understand the risks of hyperemesis gravidarum and the potential complications it may cause for both maternal and fetal health. I understand the potential risks and benefits of medications used to treat HG, including small or rare risks such as cleft lip/palate or cardiac defects with ondansetron, movement disorders with dopaminergic medications, allergic reactions, side effects, and the fact that some medication risks in pregnancy are not fully known.

I understand the purpose of HG medications, expected benefits, potential side effects, and available alternatives, including choosing not to take medications. I have had the opportunity to ask questions. I may decline or discontinue medication at any time.

I understand that many medications used to treat HG are prescribed off-label in pregnancy, and I consent to their use based on current evidence and clinical judgment.

I understand that failure to take medications as directed, obtain recommended labs, or attend follow-up visits may increase risks to me and my pregnancy. MSC is not responsible for adverse outcomes related to missed appointments, failure to obtain testing, or stopping medications without medical guidance.

I agree to use all medications only as prescribed. I will not share, sell, or misuse medications and will store them safely. I understand MSC may decline to prescribe or may discontinue medications if safety concerns arise or if clinic policies are violated. I will inform MSC of all medications prescribed by other clinicians and will not take medications not prescribed to me. 

I understand that MSC providers may adjust, modify, or decline treatments, medications, or refills if they believe it is medically unsafe or inappropriate.

I consent to medication management for hyperemesis gravidarum. I understand that medical outcomes cannot be guaranteed, and my provider has explained the risks, benefits, and alternatives to the best of their ability. I have had the opportunity to ask questions and understand that I may decline or discontinue treatment at any time.

This consent applies to all care provided by MSC, including telehealth, medication management, laboratory orders, and care coordination, unless specifically revoked in writing.

Infusion Therapy

This authorization describes risks and benefits associated with infusion therapy used to manage hyperemesis gravidarum. We often will refer you to infusion centers, who will administer their own consent for treatment, but we want you to be aware of risks and benefits. MSC does not administer IV therapy in our office. Infusions are performed at independent infusion centers. This consent is provided so you understand the risks associated with treatments we may recommend or order for you.

 
GENERAL PROCEDURE

Infusion therapy may involve intravenous fluids, vitamins, electrolytes, iron products, and/or medications.

 
RISKS AND BENEFITS

• IV Catheter Placement & Medication Infusion: allergic reaction, anaphylaxis, drowsiness, heart rhythm disturbance, infection, bruising, blood clots, and very rarely, life threatening reactions.

• IV Fluids: fluid overload, cardiac strain, pulmonary edema.

• Electrolytes: pain at the IV site, arrhythmia, or electrolyte imbalance.

• IV Iron: IV iron products may rarely cause significant infusion reactions, including low blood pressure or allergic responses. Severe reactions are very uncommon but can pose risks to both mother and fetus.

• Vitamins: Some IV vitamin formulations may contain trace elements found in standard parenteral nutrition products. These are considered safe for use in pregnancy when clinically indicated.

 
ALTERNATIVES

Alternatives include oral hydration, oral electrolyte replacement, oral vitamins, and outpatient prescription medications.

 
INFORMED CONSENT

I understand the risks and benefits of infusion therapy for HG. I may ask questions at any time. I consent to infusion therapy as recommended by my provider.

I agree to provide accurate information about my symptoms and medical history and to follow safety instructions given during infusion therapy. I understand that withholding information may increase risk.
 

 
EFFECTIVENESS

Infusion therapy is often effective but cannot be guaranteed. If I decline recommended infusion therapy or leave before treatment is complete, I understand this may increase the risks of dehydration, malnutrition, or complications of HG, and I accept responsibility for these risks.

 

Telehealth Agreement

Telehealth involves electronic communication technologies to deliver medical care from a distance. Providers may include physicians, nurse practitioners, nurses, and clinical support staff.

 
NATURE OF TELEHEALTH

Telehealth may involve sharing medical information via secure video, audio, messaging, or electronic transmission of health data. Family members, caregivers, or legal representatives may be present with your permission.

PRIVACY AND SECURITY

The privacy protections that apply to in‑person care also apply to telehealth. MSC uses HIPAA‑compliant systems. As with any electronic communication, there may be some risk of technical failure or data compromise.

 
LIMITATIONS

Telehealth may not be possible during internet outages or technical problems. In these cases, care may be rescheduled or converted to in‑person care when appropriate. 

LOCATION DISCLOSURE

I agree to accurately disclose my physical location at the start of each telehealth visit and understand that my provider may only treat me in states where they are licensed.

 
CONSENT

I understand the benefits, risks, and limitations of telehealth. I may withdraw consent at any time without affecting future care. I consent to receive telehealth services from The HG and Morning Sickness Clinic.

I understand that MSC is not an emergency service. If I experience severe symptoms—including inability to tolerate fluids for 24 hours, signs of dehydration, severe abdominal pain, chest pain, confusion, vaginal bleeding, or decreased fetal movement—I agree to seek immediate in-person medical care or call 911.

I understand that my condition may require ongoing care coordination, follow-up, and management between visits. By signing this form, I give permission for The HG and Morning Sickness Clinic to provide Principal Care Management (PCM) services when medically appropriate. PCM services may include reviewing my symptoms, adjusting my care plan, coordinating treatment with other clinicians, monitoring medications, and communicating with me between appointments.

I understand that PCM services may be billed during months when these services are provided and documented when at least 30 minutes of care management work is completed on my behalf. I acknowledge that I may be responsible for any copays, deductibles, or coinsurance determined by my insurance plan. I may withdraw this consent at any time by notifying the clinic in writing, and the withdrawal will apply to future PCM services only.

 

HIPAA Acknowledgment

I authorize The HG and Morning Sickness Clinic to release information necessary for my care to other treating providers as needed. I acknowledge receiving access to MSC’s Notice of Privacy Practices. MSC uses HIPAA‑compliant vendors for storing data, sending messages, and coordinating care.

I consent to receive communication from MSC through secure messaging, SMS texts, phone calls, and email when appropriate. I understand that MSC uses HIPAA-compliant systems, but no electronic method is entirely without risk.

I may designate support people who may communicate with MSC or receive information on my behalf. I understand MSC will only share information with individuals I have authorized in writing above.

I agree not to record audio, video, or images of telehealth or in-clinic encounters without the explicit consent of my provider. I understand my provider will not record encounters without my consent.

MSC reserves the right to terminate the provider-patient relationship when permitted by law, including for repeated missed appointments, abusive behavior, nonadherence, or safety concerns. Reasonable notice will be provided.

 

By signing, I agree to electronic records and electronic signatures.