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“Ortho Wedge Healing Shoe” has been added to your cart.
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Product
Price
Quantity
Subtotal
PEDIFIX Achilles Heel Protection Sleeve
$
36.99
PEDIFIX Achilles Heel Protection Sleeve quantity
$
36.99
Ortho Wedge Healing Shoe
$
30.84
Ortho Wedge Healing Shoe quantity
$
30.84
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Subtotal
$
67.83
Total
$
67.83
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No Fault Claim Insurance Purchase Request
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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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(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)
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Other 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.
Name
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First Name
Last Name
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Email
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DD dash MM dash YYYY
Insurance Type
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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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