Contact Us

New Patient Information

Patient Name*

First Last

Patient Email

Patient Phone*

Patient Date of Birth*

Patient Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Insurance Provider*

Partner

Would you like to include partner information?

Partner Information

Partner Name*

First Last

Partner Email

Partner Phone*

Partner Date of Birth*

Patient Primary Care Physician / OB/GYN

Provider Name

Provider Phone

Provider Fax

Office Name

Office Address

Street Address Address Line 2 City State ZIP Code

PNWF Services

Semen Analysis: Additional Information

Patient is Retrograde

Yes
No

Fertility Preservation (Sperm Cryopreservation) Additional Information

Patient is Retrograde

Yes
No

Reason for Sperm Cryopreservation

Cancer Patient
Pre-Vasectomy
Other (Provide Answer Below)

Reason for Sperm Cryopreservation

Abstinence Requirement

NO EJACULATION FOR 2-7 DAYS BEFORE TEST.

HSG: Additional Information

Medication Allergies?

Yes
No

Contrast Allergy?

Yes
No

Previous Pelvic/Abdominal Surgery?

Yes
No

Surgery: Please provide additional information

History of Pelvic infection, Chlamydia, Gonorrhea, or Hydrosalpinx/dilated fallopian tubes?

Yes
No

History: Please provide additional information

Gravidity

Parity

Allergies

Comments/Special Instructions

*Please note that ACOG recommends prophylactic antibiotics for HSG and PID:

Postoperative pelvic inflammatory disease is an uncommon but potentially serious complication in patients undergoing hysterosalpingography. Patients with dilated fallopian tubes at the time of the procedure are at greater risk than patients with non-dilated tubes. Antibiotic prophylaxis is not recommended for patients with no history of pelvic infection. If the procedure demonstrates dilated fallopian tubes, 100 mg of doxycycline may be given twice daily for five days. In patients with a history of pelvic infection, doxycycline can be administered before the procedure and continued if dilated fallopian tubes are found. ACOG Practice Bulletin No. 104: Antibiotic Prophylaxis for Gynecologic Procedures. Obstetrics & Gynecology. May 2009; Volume 113; Issue 5 pp. 1180-1189.

Additional Information

Please add any additional or miscellaneous information you'd like our patient care coordinator to know.

Next Steps

Thank you for choosing our clinic for your fertility evaluation and treatment! A patient care coordinator will reach out to schedule your appointment, or you may call our front desk at 206-515-0000.

What is three plus four?

Please answer the question in number format