PERQUE Account Request Form

Practitioner Information

First Name*

Last Name*

Phone*

Email*

Preferred Method of Communication

Phone

Email

Are you a healthcare practitioner or patient?*

Practitioner Credentials*

Credentials

Degree*

Specialty*

Year*

License #*

Institution that Granted Degree/Diploma*

Will this account be for personal/family use or for resell to clients/patients?*

Personal/Family Use Only

Clients/Patients

PRACTICE INFORMATION

Clinic or Pharmacy Name

Office address where PERQUE will be dispensed:

Office Address*

City*

State*

ZIP Code*

Office Phone

Email Address (to receive product information, promos and updates)

Would you like to receive emails about product information, promos, updates, etc.?*

Yes

No

Website

Practice Hours

Office staff providing nutritional information to patients

Office staff authorized to change Company information and place orders*

Would you like PERQUE to refer patients to you? *

Yes

No

How did you learn about PERQUE, functionally superior nutritives?*

Services Provided (check all that apply)*

Delayed Allergy Testing

Nutritional Counseling

Supplements

Chiropractic

Acupuncture

Massage

Dentistry

Other

Supplements currently or recently dispensed from this practice*

Do you agree to our terms & service?

Yes*

No

Terms of Service (Click to Review)

Do you agree to our distribution agreement?

Yes*

No

Distribution Agreement (Click to Review)

Do you agree to our minimum advertised price policy?

Yes*

No

Minimum Advertised Price (Click to Review)

Before your account can be approved, we must receive documentation of your credentials Please fax to 703-450-2995 or email to ClientServices2@PERQUE.com. Current professional license or certificate; Business card; For Student Accounts, send copy of student ID.

Promo Code

If "Other", please tell us where

By clicking "Submit", you will be entered into our email mailing list. We will not share your information with anyone.