Patient Order Form Without Doctor's Referral
(U.S. & Canada Only)
Note: If ordering without a Doctors referral you CANNOT submit to insurance for reimbursement.
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 U.S. patients; Canadian patients will be charged an additional $75.00 for shipping. If shipping outside the U.S. or Canada, please contact us for shipping costs.
A Mushroom Shipper will be shipped out unless you specify a box in the shipping notes.