Register Now

2022 Registration is now open!

We appreciate your support in this charitable initiative and your commitment to the oral health of all Canadians.

First Name *

Last Name *

Email Address *

Practice Name *

Practice Code *

Required Event Information:

Date of Give Back, Smile Back initiative *

Number of Appointments *

Required Team Information:

Please enter the number of t-shirts you will need of each size below. Every member of your team that is participating will receive a t-shirt. Please type zero if you don't require any of a particular size.

Number of Staff Participating *

Number of small t-shirts: *

Number of medium t-shirts *

Number of large t-shirts *

Number of extra-large t-shirts *

Any other information?

Is there any other information you would like us to know? *