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 $100.00 for shipping. If shipping outside the U.S. or Canada, please contact us for shipping costs.

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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*	Date you want to receive the test kit. Note: Date MUST be a valid date at least 5 days from today's date (Feb 18, 2019), 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:

A Vital Step in Screening Male Fertility.

Patient Order Form Without Doctor's Referral (U.S. & Canada Only)

A Vital Step
in Screening
Male Fertility.

Patient Order Form Without Doctor's Referral
(U.S. & Canada Only)