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 7 days from today's date (Dec 21, 2024), 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 $1,200.00 if you choose to not sign for the package if lost or stolen. If SCSA Diagnostics doesn’t receive the tank back within 15 days from delivery date you will be charged for a non-returned tank in the amount of $1,200.00.
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)