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Serving the Susquehanna Region

Thank you for taking the time to express your gratitude and helping your doctor celebrate Doctors’ Day by completing the form below.

Personal Information
In Honor of:
Please submit a second form if honoring more than one doctor.
Your note will be delivered to your physician on March 29th, and any note received after March 29th will be given to them as they are received.
Gift Information:
Please enter donation amount only i.e. 500.00
Please direct my donation to:
Pay By Credit / Debit Card:
(3-4 digit code on the back of card)

I understand that by submitting this form, I am authorizing Susquehanna Health Foundation to charge the payment information above for the amount I specified.

Your gift is tax-deductible to the fullest extent allowed by law. An acknowledgement will be sent to you in the mail for tax purposes. If you have any questions, please call 570-320-7460.