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“Drive Medical Cruiser X4 Wheelchair – Adjustable and Easy-to-Transport” has been added to your cart.
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Price
Quantity
Subtotal
Darco Night Splint Black
$
63.00
Darco Night Splint Black quantity
$
63.00
PEDIFIX Achilles Heel Protection Sleeve
$
36.99
PEDIFIX Achilles Heel Protection Sleeve quantity
$
36.99
Drive Medical Cruiser X4 Wheelchair - Adjustable and Easy-to-Transport
$
299.99
Drive Medical Cruiser X4 Wheelchair - Adjustable and Easy-to-Transport quantity
$
299.99
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Subtotal
$
399.98
Total
$
399.98
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No Fault Claim Insurance Purchase Request
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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)
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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.
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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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DD dash MM dash YYYY
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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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