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“PEDIFIX Achilles Heel Protection Sleeve” has been added to your cart.
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Product
Price
Quantity
Subtotal
Body Armor Cam Walker II Low
$
85.00
Body Armor Cam Walker II Low quantity
$
85.00
Drive Medical Wheelchair Back Cushion
$
50.00
Drive Medical Wheelchair Back Cushion quantity
$
50.00
Forearm Crutch- Adj Forearm
$
42.32
Forearm Crutch- Adj Forearm quantity
$
42.32
PEDIFIX Achilles Heel Protection Sleeve
$
36.99
PEDIFIX Achilles Heel Protection Sleeve quantity
$
36.99
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Subtotal
$
214.31
Total
$
214.31
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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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Other
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(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)
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Other Claim Insurance Purchase Request
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Name
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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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