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Product
Price
Quantity
Subtotal
OPTIFLEX ANKLE CPM
$
0.00
OPTIFLEX ANKLE CPM quantity
$
0.00
FasciaFix Plantar Fasciitis Relief Sleeve
$
25.00
FasciaFix Plantar Fasciitis Relief Sleeve quantity
$
25.00
Adjustable Cane Offset with Ergonomic Hyperlon Grip
$
25.00
Adjustable Cane Offset with Ergonomic Hyperlon Grip quantity
$
25.00
Rollator 3-Wheeled with Pouch and Basket
$
132.51
Rollator 3-Wheeled with Pouch and Basket quantity
$
132.51
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Order Summery
Subtotal
$
182.51
Total
$
182.51
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Medicare Claim Insurance Purchase Request
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Agree
No Fault Claim Insurance Purchase Request
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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
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
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
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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