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Product	Price	Quantity	Subtotal
Ice It! Headache and Migraine Kit	$38.44	Ice It! Headache and Migraine Kit quantity	$38.44
ThermaLuxe Massaging Heating Pad	$52.75	ThermaLuxe Massaging Heating Pad quantity	$52.75
Blue Jay Tennis and Golf Elbow Strap	$20.00	Blue Jay Tennis and Golf Elbow Strap quantity	$20.00

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Subtotal	$111.19
Total	$111.19

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Other Claim Insurance Purchase Request

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Name(Required)

First Name Last Name

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Email(Required)

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Mediciad

No Fault

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Other

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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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