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Product
Price
Quantity
Subtotal
FX Pro Walker High Boot
$
59.73
FX Pro Walker High Boot quantity
$
59.73
EZ Adjust Alum Crutches
$
44.99
EZ Adjust Alum Crutches quantity
$
44.99
Blue Jay Lumbar Support
$
60.00
Blue Jay Lumbar Support quantity
$
60.00
FreeStyle Libre 2 Sensor Kit
$
89.99
FreeStyle Libre 2 Sensor Kit quantity
$
89.99
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Subtotal
$
254.71
Total
$
254.71
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Workers Comp Claim Insurance Purchase Request
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(Required)
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I agree to allow CapsuleAID and its authorized representatives to contact me about my medical supplies, orders, and related subject.
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Other Claim Insurance Purchase Request
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(Required)
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(Required)
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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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