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Step 1 of 4 - Patient Information

Please fill out the form below. Any item with an asterick (*) next to is required. Canadian patients will be charged $300 for round-trip shipping.

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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
Address*:
City*:
State*:	Zip Code*:
Shipping Address
Address*:
City*:
State*:	Zip Code*:

Shipping Information
Arrival Date* (Date you want to receive the container.):	Note: Date MUST be at least 5 days greater than today's date (Sep 05, 2008) and cannot be a weekend day. 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: If you select NO, you will be financially responsible for any lost or stolen storage tanks.
Shipping Notes:

How Did You Hear of SCSA?
	Another Patient Physician RESOLVE AFA INCIID Website Infertility Publication Other
Other Notes: