Refer a Patient

Patient Information

Patient Name*

First Last

Patient Email

Patient Phone*

Patient Date of Birth*

Partner

Would you like to include partner information?

Partner Information

Partner Name*

First Last

Partner Email

Partner Phone*

Partner Date of Birth*

Referring Provider Information

Provider Name*

Provider's Electronic Signature*

Phone*

Fax

Office Name

Office Address

Street Address Address Line 2 City State ZIP Code

Diagnosis

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 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 (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 Steps

Please 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 Steps

If 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

Refer a Patient

Patient Information

Partner Information

Referring Provider Information

Diagnosis

PNWF Services

Semen Analysis: Additional Information

Fertility Preservation (Sperm Cryopreservation) Additional Information

Abstinence Requirement

HSG: Additional Information

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

Next Steps

Next Steps

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