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“SLINGSHOT 2” has been added to your cart. Continue shopping

“ObusForme Back Support Belt with Built-in Lumbar Support” has been added to your cart. Continue shopping

Product	Price	Quantity	Subtotal
Drive Medical Wheelchair Back Cushion	$50.00	Drive Medical Wheelchair Back Cushion quantity	$50.00
SLINGSHOT 2	$0.00	SLINGSHOT 2 quantity	$0.00
ObusForme Back Support Belt with Built-in Lumbar Support	$48.32	ObusForme Back Support Belt with Built-in Lumbar Support quantity	$48.32

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Subtotal	$98.32
Total	$98.32

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Name(Required)

First Name Last Name

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Insurance Type

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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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