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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
Blue Jay Slip-On Knee Support with Open Patella and Adjustable Straps
$
30.00
Blue Jay Slip-On Knee Support with Open Patella and Adjustable Straps quantity
$
30.00
IMAK Arthritis Compression Gloves
$
26.49
IMAK Arthritis Compression Gloves quantity
$
26.49
Blue Jay Premium Arthritis Compression Gloves
$
50.00
Blue Jay Premium Arthritis Compression Gloves quantity
$
50.00
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Subtotal
$
154.81
Total
$
154.81
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No Fault Claim Insurance Purchase Request
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Agree
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.
Name
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DD dash MM dash YYYY
Insurance Type
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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.
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Agree
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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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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