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).

Please allow 48 hours for your practice to be listed in the registry.

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