Refer a Patient **IF YOU ARE A PATIENT, PLEASE DO NOT FILL THIS FORM OUT** Patient InformationPatient Name* First Last Patient Email Patient Phone*Patient Date of Birth* Month Day Year Partner Would you like to include partner information? Partner InformationPartner Name* First Last Partner Email Partner Phone*Partner Date of Birth* Month Day Year Referring Provider InformationProvider Name* Provider's Electronic Signature* Phone*FaxOffice Name Office Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code DiagnosisDiagnosis Infertility Fertility Preservation PCOS Male Factor Infertility Fertility Preservation (Cancer Patient) Endometriosis LGTBQ+ family building options Fibroids Uterine Anomalies Recurrent Pregnancy Loss Tubal Disease Premature Ovarian Failure PNWF Providers* Dr. Marshall Dr. Lamb Dr. Shahine Dr. Broughton Dr. Rothenberg Dr. Zhou ARNP No Preference (will likely result in shorter wait time for consultation) PNWF ServicesPNWF Services Infertility Evaluation Donor Sperm Family Building Semen Analysis In Vitro Fertilization (IVF) Donor Egg Family Building Hysterosalpingogram (HSG) Preimplantation Genetic Testing (PGT) Fertility Preservation (Egg Freezing) Fertility Preservation (Sperm Cryopreservation) Surrogacy Sperm Preparation of IUI Semen Analysis: Additional InformationPatient is Retrograde Yes No Fertility Preservation (Sperm Cryopreservation) Additional InformationPatient is Retrograde Yes No Reason for Sperm Cryopreservation Cancer Patient Pre-Vasectomy Other (Provide Answer Below) Reason for Sperm Cryopreservation Abstinence RequirementNO EJACULATION FOR 2-7 DAYS BEFORE TEST.HSG: Additional InformationMedication Allergies? Yes No Contrast Allergy? Yes No Previous Pelvic/Abdominal Surgery? Yes No Surgery: Please provide additional informationHistory of Pelvic infection, Chlamydia, Gonorrhea, or Hydrosalpinx/dilated fallopian tubes? Yes No History: Please provide additional informationGravidity Parity Allergies Comments/Special Instructions (i.e. Are you prescribing Valium for your patient?)*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.Next StepsPlease send patient’s medical records and insurance information via fax, 206-515-0001 .If this is an urgent matter, please call during business hours and ask to speak with a manager or one of our providers. Referring patients can call our clinic to check on the status of their referral and schedule their appointment. Results will be faxed to the referring provider to be reviewed with the patient. PNWF does not review results directly with patients, they are reviewed by referring provider.Next StepsIf this is an urgent matter, please call during business hours to speak with a manager or one of our providers. Referring patients are required to call our clinic to schedule appointments or check on the status of their referral. PNWF DOES NOT CONTACT REFERRAL PATIENTS TO SCHEDULE APPOINTMENTS. Results will be faxed to the referring provider to be reviewed with the patient. PNWF does not review results directly with patients, they are reviewed by the referring provider