Register Now

Registration Deadline is Friday, February 5, 2021

We appreciate your support in this amazing 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 *

Name of Chosen Charity *

Number of Appointments *

Number of Oral Health Kits (1 per patient) *

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?

Media Opportunities

Give Back, Smile Back is a great opportunity for community exposure. dentalcorp will assist for media pitches and PR opportunities.

Would you like photography of the event? *

Yes

Please contact me to discuss

Would you like to explore media opportunities in your community, such as press releases, asking for a reporter to visit your Practice, etc.? *

Yes

Please contact me to discuss

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