SECURE ONLINE DONATION
COLQUITT REGIONAL MEDICAL FOUNDATION
YOUR CONTACT INFORMATION
Donor Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Any size donation is accepted to honor your Doctor Hero! (we request one donation per doctor)
With a $250 gift, you may choose to honor every active physician on our Medical Staff.
Please accept my donation of
$20
$50
$100
$250
Other
I choose to honor
Please Select
An Individual Doctor
The Entire Medical Staff
Name of Individual Doctor
Tribute message to Doctor:
Payment Method
*
Please Select
Credit/Debit Card (ENTER CARD INFO BELOW.)
Colquitt Regional Payroll Deduction (THEN SKIP TO SUBMIT)
Colquitt Regional Employees, if you choose to payroll deduct your gift then skip ahead to verify you are human then click the SUBMIT button. (You will bypass the amount/credit card details section.)
Amount
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USD
Description
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