PERQUE Account Request Form

Practitioner Information

Preferred Method of Communication


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


Office address where PERQUE will be dispensed:
Would you like to receive emails about product information, promos, updates, etc.?*
Would you like PERQUE to refer patients to you? *
Services Provided (check all that apply)*
Do you agree to our terms & service?
Terms of Service (Click to Review)
Do you agree to our distribution agreement?
Distribution Agreement (Click to Review)
Do you agree to our minimum advertised price policy?
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 Current professional license or certificate; Business card; For Student Accounts, send copy of student ID.
How did you hear about us?*

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