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Product
Price
Quantity
Subtotal
BlueJay Folding Cane
$
25.00
BlueJay Folding Cane quantity
$
25.00
Push Button Aluminum Adjustable Crutch
$
28.02
Push Button Aluminum Adjustable Crutch quantity
$
28.02
Sockless Insoles w/Terry Comfort
$
11.99
Sockless Insoles w/Terry Comfort quantity
$
11.99
SLINGSHOT 2
$
0.00
SLINGSHOT 2 quantity
$
0.00
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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Order Summery
Subtotal
$
165.00
Total
$
165.00
Proceed to checkout
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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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Date of Birth
(Required)
DD dash MM dash YYYY
Insurance Type
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No Fault
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Other
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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
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)
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
Best Sellers
Drive Medical Deluxe Folding Walker, Two Button
$
62.99
Drive Medical Wheelchair Back Cushion
$
50.00
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$
25.00
Eggcrate Wheelchair Cushion with Back
$
30.00
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