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“FasciaFix Plantar Fasciitis Relief Sleeve” has been added to your cart.
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Product
Price
Quantity
Subtotal
FasciaFix Plantar Fasciitis Relief Sleeve
$
25.00
FasciaFix Plantar Fasciitis Relief Sleeve quantity
$
25.00
EZ Adjust Alum Crutches
$
44.99
EZ Adjust Alum Crutches quantity
$
44.99
Sockless Insoles w/Terry Comfort
$
11.99
Sockless Insoles w/Terry Comfort quantity
$
11.99
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Order Summery
Subtotal
$
81.98
Total
$
81.98
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Medicare Claim Insurance Purchase Request
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Agree
No Fault Claim Insurance Purchase Request
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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
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
(Required)
First Name
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(Required)
Email
(Required)
Date of Birth
(Required)
DD dash MM dash YYYY
Insurance Type
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Mediciad
No Fault
Workers Comp
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)
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
(Required)
First Name
Last Name
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(Required)
Email
(Required)
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(Required)
DD dash MM dash YYYY
Insurance Type
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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