Order a PVSA Test [Premier Vasectomy]

Patient Name(Required)

First Last

Patient Date of Birth(Required)

Date of Vasectomy(Required)

Date to Send Kit(Required)

Send 12 weeks after Date of Vasectomy above

Send 14 weeks after Date of Vasectomy above

I will set the date to send below.

Choose a Custom Date to Send Kit

Patient Phone(Required)

Patient Email

Patient Shipping Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Ordering Provider

Shipping Notes or Special Instructions