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Product
Price
Quantity
Subtotal
Adjustable Cane with Vinyl Grip
$
35.00
Adjustable Cane with Vinyl Grip quantity
$
35.00
Forearm Crutch- Adj Forearm
$
42.32
Forearm Crutch- Adj Forearm quantity
$
42.32
Toe Alignment Splint
$
20.11
Toe Alignment Splint quantity
$
20.11
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Subtotal
$
97.43
Total
$
97.43
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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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Other Claim Insurance Purchase Request
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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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