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Product
Price
Quantity
Subtotal
POLAR CARE COLD THERAPY
$
31.59
POLAR CARE COLD THERAPY quantity
$
31.59
Underpads Economy 150/cs
$
51.32
Underpads Economy 150/cs quantity
$
51.32
ThermaLuxe Massaging Heating Pad
$
52.75
ThermaLuxe Massaging Heating Pad quantity
$
52.75
Theratherm Moist Heat Pad
$
92.90
Theratherm Moist Heat Pad quantity
$
92.90
Aircast AirSport Ankle Brace
$
59.99
Aircast AirSport Ankle Brace quantity
$
59.99
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Subtotal
$
288.55
Total
$
288.55
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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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Max. file size: 2 GB.
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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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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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