Physician Referral Forms


 

Semen Analysis Requisition Form

HSG Requisition Form

To Order a Semen Analysis:

  • Please complete and fax the Semen Analysis Requisition Form to our office (972-506-0044).
  • The patient needs to call our office (972-506-9986) to confirm the appointment for the semen analysis.
  • A 3-4 days period of abstinence is recommended before semen collection.

To Order a HSG:

  • Please complete and fax the HSG Requisition Form to our office (972-506-0044).
  • Please have your patient call our clinic (972-506-9986) to confirm the appointment for the HSG.
  • It’s best to schedule the HSG between the 7th to10th day of the cycle.
  • Please prescribe for your patient antibiotic prophylaxis for the test.

We appreciate your referrals!

 

Note: These files are in PDF format. If you do not have Adobe® Reader® on your computer, you can download it for free by clicking here or on the Get Adobe Reader icon.

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