Dry Shipper Order Form

This order form is for hospitals, clinics or labs. All of the listed items below are required.

Click Here to download the credit card authorization form.
Click Here to download a requisition form.
Click Here for lab collection directions.

Lab Information
Name of the Person Ordering the Shipper:
Name of Hospital / Lab / Clinic:
Address:
City:
State:
Zip Code:
Phone:	(format: 888-888-8888)
Fax:	(format: 888-888-8888)
Email:
Patient(s) Name:
Notes:
Include Collection Cup & Vials.

Shipping Information
Arrival Date:
	Your date must be a valid date at least 7 days from today's date (Nov 21, 2024), or 8 days from today's date if submitting this order after 3:30 PM Central Time or anytime on a Friday, and cannot be on a weekend day or a holiday. 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.

Verification
	I have viewed sample preparation and abstinence guidelines on the SCSA Diagnostics website.
	I understand that a delivery signature will be required.
	Please Note: If the patient cancels or doesn’t show up for collection of sample the patient is responsible for the shipping charges, if the patient refuses or doesn’t pay, it will be the responsibility of the clinic to pay for the shipping charges in the amount of $150.00 to SCSA Diagnostics. Please make sure to notify your patients of this charge before ordering the Dry Shipper.

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

A Vital Step in Screening Male Fertility.