HSG Referral Form

Coastal Fertility Specialists

Hysterosalpingogram (HSG) Referral Form

Thank you for your continued referrals to Coastal Fertility Specialists! By simply completing the form below and pressing send one of our new patient coordinators will contact your patient within one business day to schedule the hysterosalpingogram. There's nothing more to it than that! No more messing with faxes or other nonsense. :-) www.infertilityconsult.com

We typically perform HSG's between days 6 to 14 of a patient's menstrual cycle. You will receive a preliminary report faxed to your office within 24 hours of the procedure and final report within 7 to 10 days by mail.

This web form is HIPAA compliant with SSL technology to encrypt all communication. If at anytime you feel a patient is dissatisfied with our care, has unanswered questions or if there is something more we can do to help you please call us or include it in form below. Hope you are having a great day!

First Name *

Middle Initial

Last Name *

Date of Birth: +

Patient Phone Number: *

Referring Doctor First Name *

Referring Doctor Last Name *

Fax Number for Results *

Anything in particular you want us to know about this patient?