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Product
Price
Quantity
Subtotal
Blue Jay Tennis and Golf Elbow Strap
$
20.00
Blue Jay Tennis and Golf Elbow Strap quantity
$
20.00
Stabilising Knee Sleeve
$
25.00
Stabilising Knee Sleeve quantity
$
25.00
Visco-GEL Achilles Protection Sleeve
$
28.59
Visco-GEL Achilles Protection Sleeve quantity
$
28.59
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Order Summery
Subtotal
$
73.59
Total
$
73.59
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No Fault Claim Insurance Purchase Request
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(Required)
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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(Required)
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(Required)
DD dash MM dash YYYY
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Mediciad
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Other
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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
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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First Name
Last Name
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Email
(Required)
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(Required)
DD dash MM dash YYYY
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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Universal Arm Sling, Envelope Style, Navy Blue, Poly-Cotton, Adjustable Strap
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Stabilising Knee Sleeve
$
25.00
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