Register Your Practice

By submitting this form, you agree to participate in the Halloween Candy Buy-Back Program, "buy" candy back from children during a stated period of time following Halloween, and send the collected candy to Operation Gratitude (or other Military support organization).

Practice Name:
Your Name:
(if different from above)
Street Address:
Zip Code:
ex: 12345 or A12B3C
Phone Number:
ex: 1234567890
Fax Number:
ex: 1234567890
Email Address:

Allow information to show up in our member directory