Fertility Answers - Helping Build Families

Patient Referral Form

**** Referring Physicians Only ****

Patient Referral Form

Baton Rouge: (225) 926-6886   Lafayette: (337) 989-8795

Thank you for the referral of your patient! We appreciate your confidence in Fertility Answers and will do everything possible to ensure your patient is well cared for.

  • The referring doctor will be provided with a follow-up referral letter after the consultation outlining the plan for future treatment. Please feel free to contact our office or physician ahead of the appointment if the patient has any special needs or considerations.
  • For semen analysis referrals, please provide your patient with these Instructions for Semen Specimen Collection. We will contact the patient to schedule after at least two days of ejaculatory abstinence. If special orders are required, please note this on the referral form. Please do not send the patient for an SA without an appointment
  • HSG referrals can be scheduled even if you are not referring the patient for infertility treatment. We will contact the patient and schedule her during the follicular phase of her cycle. A complete HSG report will be sent to you on the next business day. Actual images are available (hard copy or digital) upon request.

Physician Office Instructions: Please fill out completely and click SUBMIT. Once we receive the form, we will contact the patient directly to schedule the appointment.

 

Fertility Answers Referral Form

"*" indicates required fields

Referral Date*
Patient Date LMP (if applicable)
Referring Physician/Clincian Email*
Reason for Referral (check all that apply)*
Drop files here or
Max. file size: 50 MB.
    Physician Consent for Referral*