Physician Referral Forms

972.506.9986 Irving, TX 817.701.1290 Arlington, TX

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.

IVFMD serves the Dallas Fort Worth metroplex from its 2 fully equipped IVF centers in Irving and Arlington with results-driven, affordable and individualized fertility care.

Year after year, our experienced team has continued to celebrate successes alongside our IVFMD families. Our fertility team would like nothing more than to share that experience with you.

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