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Product
Price
Quantity
Subtotal
Gel Wheelchair Cushion
$
30.86
Gel Wheelchair Cushion quantity
$
30.86
Eggcrate Wheelchair Cushion with Back
$
30.00
Eggcrate Wheelchair Cushion with Back quantity
$
30.00
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Subtotal
$
60.86
Total
$
60.86
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Workers Comp Claim Insurance Purchase Request
To complete this order we need some information, please fill out below to the best of your ability and our team will contact you if there are any additional requirements.
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(Required)
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Other Claim Insurance Purchase Request
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DD dash MM dash YYYY
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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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Eggcrate Wheelchair Cushion with Back
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