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Professional Account Request Form

Dear Medical Professional:
Thank you for your request to open a Therapeutica account. In order to provide professional pricing, we need to verify your credentials. Please complete the questions below and either fax, e-mail, or mail us ONE of the following:

  • Your URL (professional website address)
  • A copy of your license
  • Business card
  • Clinic letterhead
Upon receipt of this information, we will forward to you pricing and product information. We will retain your contact information in our company records for future inquires.

We look forward to answering any questions you may have.

Fax: 416-289-9664/ 1-866-348-5721
E-mail: info@therapeutica.com
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