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“Darco Med-Surg Shoe Mens” has been added to your cart. Continue shopping

“Artromot Elbow CPM Machine with Full Range of Motion and Anatomical Motion Design” has been added to your cart. Continue shopping

Product	Price	Quantity	Subtotal
Hydrocollator Heat Pack	$36.05	Hydrocollator Heat Pack quantity	$36.05
Darco Med-Surg Shoe Mens	$25.00	Darco Med-Surg Shoe Mens quantity	$25.00
Artromot Elbow CPM Machine with Full Range of Motion and Anatomical Motion Design	$0.00	Artromot Elbow CPM Machine with Full Range of Motion and Anatomical Motion Design quantity	$0.00

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Subtotal	$61.05
Total	$61.05

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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)

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Workers Comp Claim Insurance Purchase Request

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Name(Required)

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Email(Required)

Date of Birth(Required)

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Insurance Type

Medicare

Mediciad

No Fault

Workers Comp

Other

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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(Required)

First Name Last Name

Phone Number(Required)

Email(Required)

Date of Birth(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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