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

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Note: If ordering without a Doctors referral you CANNOT submit to insurance for reimbursement.

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 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.

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)
(format: 888-888-8888)
Home Address (Please use the billing address of your credit card)
Zip Code*:
Shipping Address (FedEx does not deliver to PO boxes)
Zip Code*:
Shipping Information
Arrival Date*
Date you want to receive the test kit.

Note: Date MUST be a valid date at least 7 days from today's date (Nov 28, 2023), or 8 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 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 $1,200 if you choose to not sign for the package if lost or stolen.
Shipping Notes:
How Did You Hear of SCSA?
Another Patient
Infertility Publication
Other Notes: