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Product
Price
Quantity
Subtotal
DCS Plantar Fasciitis Sleeve
$
25.00
DCS Plantar Fasciitis Sleeve quantity
$
25.00
Sockless Insoles w/Terry Comfort
$
11.99
Sockless Insoles w/Terry Comfort quantity
$
11.99
ADVANCED ORTHOPAEDICS SHOULDER ABDUCTION PILLOW
$
0.00
ADVANCED ORTHOPAEDICS SHOULDER ABDUCTION PILLOW quantity
$
0.00
PEDIFIX Achilles Heel Protection Sleeve
$
36.99
PEDIFIX Achilles Heel Protection Sleeve quantity
$
36.99
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Order Summery
Subtotal
$
73.98
Total
$
73.98
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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.
Name
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Insurance Type
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Workers Comp
Other
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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.
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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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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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