Physician Referral Forms

Semen Analysis Requisition Form

HSG Requisition Form

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.

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 Irving office (972-506-0044) or to our Arlington office (817-701-1297).
• Please have your patient call our clinic in Irving (972-506-9986) or in Arlington (817-701-1290) to confirm the appointment for the HSG.
• It’s best to schedule the HSG between the 7th and 10th day of the cycle.
• Please prescribe for your patient antibiotic prophylaxis for the test.

We appreciate your referrals!