Dry Shipper Order Form

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This order form is for hospitals, clinics or labs. All of the listed items below are required.

Click Here to download the credit card authorization form.
Click Here to download a requisition form.
Click Here for lab collection directions.

Lab Information
Name of the Person Ordering the Shipper:
Name of Hospital / Lab / Clinic:
Address:
City:
State:
Zip Code:
Phone:	(format: 888-888-8888)
Fax:	(format: 888-888-8888)
Email:
Notes:
Include Collection Cup & Vials.

Shipping Information
Arrival Date:
	Your date must be a valid date at least 7 days from today's date (Apr 26, 2024), and cannot be on a weekend day or a holiday. If you need the tank before the date given please call us for tank availability. Holiday Notice - Click to View Please be aware that FedEx is closed on the following holidays - Memorial Day, Labor Day, 4th of July, Thanksgiving, Christmas and New Year's Day. If you schedule a Home Collection Kit to arrive on one of these holidays, it will not arrive until the day after the holiday.

Verification
	I have viewed sample preparation and abstinence guidelines on the SCSA Diagnostics website.
	I understand that a delivery signature will be required.

SCSA Diagnostics, Inc
425 8th Street South
Brookings, SD 57006

A Vital Step in Screening Male Fertility.