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Product
Price
Quantity
Subtotal
Walker Folding 2-Button Adult Aluminum
$
41.54
Walker Folding 2-Button Adult Aluminum quantity
$
41.54
Underpads Economy 150/cs
$
51.32
Underpads Economy 150/cs quantity
$
51.32
Theratherm Moist Heat Pad
$
92.90
Theratherm Moist Heat Pad quantity
$
92.90
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Subtotal
$
185.76
Total
$
185.76
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Workers Comp Claim Insurance Purchase Request
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Other Claim Insurance Purchase Request
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Name
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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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