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Product
Price
Quantity
Subtotal
Softie Surgical Shoe Womens
$
16.12
Softie Surgical Shoe Womens quantity
$
16.12
Blue Jay Lumbar Support
$
60.00
Blue Jay Lumbar Support quantity
$
60.00
Blue Jay Universal Arm Sling
$
20.00
Blue Jay Universal Arm Sling quantity
$
20.00
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Order Summery
Subtotal
$
96.12
Total
$
96.12
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Agree
Workers Comp Claim Insurance Purchase Request
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(Required)
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(Required)
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(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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(Required)
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(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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