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Product
Price
Quantity
Subtotal
PEDIFIX Achilles Heel Protection Sleeve
$
36.99
PEDIFIX Achilles Heel Protection Sleeve quantity
$
36.99
AFO (Ankle-Foot Orthosis) Brace
$
39.99
AFO (Ankle-Foot Orthosis) Brace quantity
$
39.99
Gel Insoles for Women with Shock Absorbing Cushion
$
14.71
Gel Insoles for Women with Shock Absorbing Cushion quantity
$
14.71
Softie Surgical Shoe Womens
$
16.12
Softie Surgical Shoe Womens quantity
$
32.24
Darco Med-Surg Shoe Black Square-Toe
$
19.27
Darco Med-Surg Shoe Black Square-Toe quantity
$
19.27
Sockless Insoles w/Terry Comfort
$
11.99
Sockless Insoles w/Terry Comfort quantity
$
11.99
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Order Summery
Subtotal
$
155.19
Total
$
155.19
Proceed to checkout
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No Fault Claim Insurance Purchase Request
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Max. file size: 2 GB.
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(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
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(Required)
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(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
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First Name
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(Required)
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DD dash MM dash YYYY
Insurance Type
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Mediciad
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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)
Agree
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