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“FasciaFix Plantar Fasciitis Relief Sleeve” has been added to your cart. Continue shopping

“Blue Jay Perfect Measure Big Digit Talking Dlx BP Monitor” has been added to your cart. Continue shopping

Product	Price	Quantity	Subtotal
FasciaFix Plantar Fasciitis Relief Sleeve	$25.00	FasciaFix Plantar Fasciitis Relief Sleeve quantity	$25.00
Blue Jay Perfect Measure Big Digit Talking Dlx BP Monitor	$50.00	Blue Jay Perfect Measure Big Digit Talking Dlx BP Monitor quantity	$50.00

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Subtotal	$75.00
Total	$75.00

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Other Claim Insurance Purchase Request

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Name(Required)

First Name Last Name

Phone Number(Required)

Email(Required)

Date of Birth(Required)

DD dash MM dash YYYY

Insurance Type

Medicare

Mediciad

No Fault

Workers Comp

Other

Insurance Provider(Required)

Insurance ID(Required)

Documents Section Upload (i.e. prescriptions)

Max. file size: 2 GB.

I agree to allow CapsuleAID and its authorized representatives to contact me about my medical supplies, orders, and related subject.(Required)

Agree

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