Patient Order Form With Doctor's Referral
(U.S. Only)
Due to recent shipping issues, we are temporarily suspending all shipments to Canada.

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 $500.00 for U.S. patients. If shipping outside the U.S., please contact us for shipping costs.

A Mushroom Shipper will be shipped. Click here to view the items you will be receiving.

  • Step:
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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*:
 (format: 888-888-8888)
Daytime Phone / Work*:
 (format: 888-888-8888)
Cell:
 (format: 888-888-8888)
Email*:
 
Home Address (Please use the billing address of your credit card)
Address*:
City*:
State*:
Zip Code*:
 
Shipping Address (FedEx does not deliver to PO boxes)
Address*:
City*:
State*:
Zip Code*:
 
Shipping Information
Arrival Date*
 The earliest arrival date available is 11/05/2026
Date you want to receive the test kit.
Note: Date cannot be on a weekend day or a holiday. If you require expedited shipping, please note that in the shipping notes and we will do our best to accommodate if possible. 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 $1,650.00 if you choose to not sign for the package if lost or stolen. If SCSA Diagnostics doesn’t receive the tank back within 15 days from delivery date you will be charged for a non-returned tank in the amount of $1,650.00.
Shipping Notes:
 
How Did You Hear of SCSA?
 
Another Patient
Physician
RESOLVE
AFA
INCIID
Website
Infertility Publication
Other
Other Notes:

Patient IconPATIENT INFORMATION

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

Toll Free: 1-866-219-1338
Email: scsa@scsatest.com

© 2026 SCSA Diagnostics.
All Rights Reserved


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