Patient Order Form For International Patients
(With U.S. Doctor)

Order Now
Step 1 of 4 - Patient Information

Please fill out the form below. Any item with an asterisk (*) next to it is required. The total cost of the SCSA Test is $450.00 for international patients. If shipping outside the U.S., please contact us for shipping costs.

A Mushroom Shipper will be shipped out unless you specify a box in the shipping notes.

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Fields marked with * are required.
Patient Name and Partner Information
First Name*:

(patient providing semen sample)
Last Name*:
Date of Birth*:
Partner Full Name*:
 
Contact and Mailing Information
Phone / Email
Home Phone*:
Daytime Phone / Work*:
Cell:
Email*:
 
Home Address (Please use the billing address of your credit card)
Address*:
City*:
Country*:
Postal Code*:
 
Shipping Address (FedEx does not deliver to PO boxes)
Address*:
City*:
State*:
Zip Code*:
 
Shipping Information
Arrival Date*
Date you want to receive the test kit.

Note: Date MUST be a valid date at least 5 days from today's date (Feb 26, 2017), or 6 days from today's date if submitting this order after 3:30 PM Central Time, and cannot be on a weekend day or a holiday. If you require expedited shipping, please contact us for overnight shipping at additional cost. 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.
Delivery Signature Required? Yes No
  Note: You will be financially responsible for the tank in the amount of $1,200 if you choose to not sign for the package if lost or stolen.
Shipping Notes:
 
How Did You Hear of SCSA?
 
Another Patient
Physician
RESOLVE
AFA
INCIID
Website
Infertility Publication
Other
Other Notes: