PERQUE Account Request Form

Practitioner Information

Credentials

PRACTICE INFORMATION

Office address where PERQUE will be dispensed:
Terms of Service (Click to Review)
Distribution Agreement (Click to Review)
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.

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