When to Refer
Most infertility concerns are resolved with conservative interventions such as clomid, insemination, or surgery. Referral to a fertility specialist is recommended when:
• Female is age 38 or older.
• Inability to conceive within 6-12 months of discontinuing contraception.
• Blocked fallopian tubes.
• Other tubal problems such as more than one tubal ectopic pregnancy.
• Moderate or severe endometriosis.
• Significant male factor – sperm concentration less than 10 million per ml, or motility less than 40%.
• Ovulation problems such as polycystic ovarian syndrome, (PCOS) treated with 3 to 6 months of clomid without conception.
• Abnormal ovarian reserve tests, such as elevated day 3 FSH level or AMH less than one.
SRM Referral Form – Download, Print and Fax
Use the Infertility Referral Services Form (.pdf) to refer your patients to SRM for Andrology Diagnostic Services (Semen Analysis and IUI), Hystersalpingogram Services (HSG) and General Infertility Services. Please fill out the appropriate sections and fax the referral form to 206-301-5679. The original referral form is given to your patient. Additional referral forms can be requested by calling 206-301-5000 or toll free at 877-777-6002 or email firstname.lastname@example.org.
HOW TO REFER FOR FERTILITY TREATMENT
For fertility concerns as described above, your patient can call SRM for their initial intake at 206-301-5000 or toll free at 877-777-6002. Appropriate medical records can be requested and faxed to: 206-301-5679.
REFERRING FOR HSG’S
We request a written referral be sent to SRM prior to the patient scheduling an appointment for an HSG. All information in the HSG section of the referral form needs to be filled out. Checkmark “Please perform an HSG on my patient.” Referrals are faxed to SRM and the original is given to your patient. HSG’s are performed by a physician or nurse practitioner. Results of HSG’s are provided to the referring doctor typically within 7-10 business days.
REFERRING FOR SEMEN ANALYSIS
We request a written referral be sent to SRM prior to the patient scheduling an appointment for a Semen Analysis. All information in the Andrology section of the referral form needs to be filled out. Male patient’s name is required. Checkmark “Semen Analysis” for referral. Referrals are faxed to SRM and the original is given to your patient. SA’s are available at ALL locations. Results of SA’s are provided to the referring doctor typically within 7-10 business days. For abnormal tests we recommend a second test.
For SRM Marketing Materials
To request additional SRM referral pads, business cards, brochures, etc., please call 206-301-5000 or toll free at 877-777-6002 or email email@example.com.
Additionally, you can contact your Physician Liaison directly based on your location:
Western Washington, Tri-Cities or Alaska
Jessica Allen – firstname.lastname@example.org or 813 810 8885
Eastern Washington, Spokane, Idaho, Montana
Tracy Love – email@example.com or 509 785 4224