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!