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“Drive Medical Adjustable Tension Wheelchair Back Cushion – Customizable Comfort and Support” has been added to your cart.
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Product
Price
Quantity
Subtotal
Blue Jay Lumbar Support
$
60.00
Blue Jay Lumbar Support quantity
$
120.00
BIOMET® EBI BONE HEALING SYSTEM®
$
0.00
BIOMET® EBI BONE HEALING SYSTEM® quantity
$
0.00
IMAK Arthritis Compression Gloves
$
26.49
IMAK Arthritis Compression Gloves quantity
$
26.49
Drive Medical Adjustable Tension Wheelchair Back Cushion – Customizable Comfort and Support
$
99.99
Drive Medical Adjustable Tension Wheelchair Back Cushion – Customizable Comfort and Support quantity
$
99.99
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Subtotal
$
246.48
Total
$
246.48
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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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(Required)
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Insurance Type
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(Required)
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(Required)
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Max. file size: 2 GB.
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Other Claim Insurance Purchase Request
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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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