Instructions for hsg and/or tubal cannulation

INSTRUCTIONS FOR HYSTEROSALPINGOGRAM (HSG) AND/OR
TUBAL CANNULATION REFERRING PHYSICIAN PATIENTS
Call between 9:00 am and 4:00 pm Monday-Friday to schedule your HSG. This The HSG will be performed in our SOMERSET OFFICE
No intercourse from day 1 of your period until the completion of the HSG.
You MUST obtain a prescription for an antibiotic (Vibramycin 100
You will be taking one tablet twice a day for five days starting the day
before the procedure. (10 tablets)
Take (4) Advil or Motrin for a total of 800 mg one hour before the procedure.
If you have had an HSG previously, obtain a copy of your films prior to the Please arrive 15 minute prior to the procedure to the SOMERSET OFFICE (81
Veronica Avenue).
Upon arrival to the Somerset office the nurse will do a urine pregnancy test
before the HSG is performed.
IMPORTANT: If a referral is required it is your responsibility to bring the
referral the day of the procedure. If you do not have a referral we will not
be able to perform the procedure.
Please read and sign the "Notice of Privacy Practices" and bring in with
you the day of your appointment.
PROTOCOL FOR ASTHMATICS AND PATIENTS ALLERGIC TO
X-RAY CONTRAST
If you have a history of asthma or are allergic to x-ray contrast you MUST let
your physician know so you can obtain a prescription for PREDNISONE 20 mg.
The prednisone is to be taken as follows: (6 tablets)
2 tablets - the morning the day before the exam 2 tablets - the evening the day before the exam.
2 tablets - the morning of the exam.
A patient is considered "allergic" if, at an earlier date, she developed any of the following symptoms from IV contrast - sneezing, nasal congestion, hives, chest tightness, breathing difficulty, sensation of a lump in the throat, wheezing or diffuse redness of the skin.
IMPORTANT INFORMATION
Please fax your insurance card both front and back,
as soon as possible.
4. Policy holders (1) Name (2) date of birth Fax to: (732) 545-1164
If we do not have the above information prior to your appointment you may be
responsible for payment on the day of your visit.
Please Note:
Some insurance plans require a referral and/or pre-authorization. It is your responsibility to bring the referral and/or the pre-authorization to your appointment. Failure to do so may result in you being responsible for full payment on the date of service.
If you have any questions regarding billing please contact our billing department.
BILLING DEPARTMENT
732-545-1186
Authorization and Benefits Ext. 619
OUTSIDE HSG
POST ESSURE HSG
Patient's Name _______________________________ Date of Birth___________ Social Security Number ___________-____________-_______________ Address_________________________________________________________ ________________________________________________________________ Home Phone ______________________ Work Phone ______________________ Appointment Date _________________ Appointment Time__________________ Physician referring you to IVF NJ ______________________________________
(First and Last Name)
___________________________________________________________________ Physician patient is seeing ____________________________________________ Date information packet mailed out_____________________________________ INSURANCE INFORMATION
Insurance Company (PATIENT) _____________________________________________
ID # ___________________________________ Group ______________________ Subscriber's Name _________________________________ Customer Service # ________________________________

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