Skip Navigation LinksProvider Registration

You may register as an individual, school, wellness center, rehab clinic, spa, doctor, or any other health care provider or facility.


Please enter your email address:


Please verify your email address:


Please enter your password:


Please verify your password:





Please enter your tracking period in months (this is the time frame to track the number of free sessions you provide)


Please specify your goal (the number of free sessions you would like to provide in your tracking period)


Please specify the type(s) of service you are willing to provide free of charge:





What is the name of the business:


What is the name of the main contact for the business:


Please enter the complete address of the business:
 (Address 1)
 (Address 2)
 (City)   (State)   (Zip Code)

Please enter your phone numbers:
( -  (Work Phone)
( -  (Cell Phone)




Would you like your name to appear on our website and advertising as a "Hands for Heroes Partner™"?


Would you like to receive possible referrals from "Hands for Heroes™"?





List your health care modality(ies):


List any State/National License you currently hold:


Comments:





I give permission to list the testimonial in the advertising and / or on the website: