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Product
Price
Quantity
Subtotal
ObusForme Back Support Belt with Built-in Lumbar Support
$
48.32
ObusForme Back Support Belt with Built-in Lumbar Support quantity
$
48.32
Aircast SP Walker Low Rocker Sole Walking Boot
$
109.90
Aircast SP Walker Low Rocker Sole Walking Boot quantity
$
109.90
Adjustable Back Support with Tension Straps
$
39.99
Adjustable Back Support with Tension Straps quantity
$
39.99
Blue Jay Universal Back Support Brace
$
45.00
Blue Jay Universal Back Support Brace quantity
$
45.00
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Subtotal
$
243.21
Total
$
243.21
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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)
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I agree to allow CapsuleAID and its authorized representatives to contact me about my medical supplies, orders, and related subject.
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Other Claim Insurance Purchase Request
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Name
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Mediciad
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Workers Comp
Other
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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)
Agree
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