Donate Now

Please complete the form below to make your donation. Your support of Good Samaritan Hospital Medical Center enables our patients to receive extraordinary care in their greatest time of need.

 

Donation Information
Amount:	$ 50.00 $ 100.00 $ 250.00 $ 500.00 $ 1,000.00 Other $     *
Designation:	Please use my gift wherever it is most needed Campaign for the Stroke & Brain Aneurysm Center Breast Health Center BirthPlace Cancer Cardiology Pediatrics Neonatal Intensive Care Unit Community Health Programs
Additional Information
Type of gift:	One-time gift Recurring gift
Frequency:	Weekly Monthly Quarterly Annually On:   Sunday Monday Tuesday Wednesday Thursday Friday Saturday Starting:    Ending:   Ending:
Corporate:	This donation is on behalf of a company
Anonymous:	I prefer to make this donation anonymously
Comments:
Billing Information
Title:	<Please select> Dr. Mr. Ms. Mrs. Drs. Miss Master Prof. Hon. The Honorable Judge Bishop Rev. Msgr. Msgr. Most Rev. Rev. Pastor Sister Father Brother Deacon Rabbi Governor Senator Congressman Assemblyman Assemblywoman Lt. Capt. Major Cmdr. Col. Admiral General Ambassador Sir Madam Sir/Madam Elder Sr. Sheriff Mayor Inspector Min. Minister Chief Messrs. Sgt. Mr. & Mrs. Dr. & Mrs. Dean Legislator Detective Sgt. & Mrs. Det. & Mrs. Rev. & Mrs. Deputy Chief Hon. & Mrs. Ms Det. PO Chaplain Rev. Dr. Principal County Executive Councilwoman Suffolk County Treasurer County Legislator Supervisor Islip Town Supervisor Executive Town Clerk Town Councilman Councilman , Sr. Rev. Fr. . Chef The Mr. and Mrs.	*
First name:		*
Last name:		*
Country:	USA ESS England United States	*
Address lines:		*
City:		*
State:	<Please Select> AA AB AE AK AL AP AR AS AZ BC CA CO CT CZ DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NL NH NJ NM NS NT NU NV NY OH OK ON OR PA PE PR PW QC RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT	*
ZIP:		*
Phone:		*
Email:		*
Payment Information
Cardholder's Name:		*
Credit Card Number:		*
Card Type:	Visa American Express Discover Maestro MasterCard	*
Valid From:	01 02 03 04 05 06 07 08 09 10 11 12  / 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018  (Maestro/Switch/Solo only)
Card Expiration:	01 02 03 04 05 06 07 08 09 10 11 12  / 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032	*
Issue Number:	(Maestro/Switch/Solo only)
Card Security Code:		*
	Note: The Card Security Code is not required for Maestro, Switch and Solo cards.
Matching Gifts
	My company will match my gift
Company:		*
Tribute Information
Type:	In Memory Of In Honor Of	*
Name:		*
First name:
Last name:		*
	Mail a letter on my behalf to	*

 

Donation Information
Amount:	$ 50.00 $ 100.00 $ 250.00 $ 500.00 $ 1,000.00 Other $     *
Designation:	Please use my gift wherever it is most needed Stroke & Brain Aneurysm Center Breast Health Center BirthPlace Cancer Cardiology Pediatrics Neonatal Intensive Care Unit Community Health Programs
Additional Information
Frequency:	Weekly Monthly Quarterly Annually On:   Sunday Monday Tuesday Wednesday Thursday Friday Saturday Starting:    Ending:   Ending:
Corporate:	This donation is on behalf of a company
Anonymous:	I prefer to make this donation anonymously
Comments:
Billing Information
Title:	<Please select> Dr. Mr. Ms. Mrs. Drs. Miss Master Prof. Hon. The Honorable Judge Bishop Rev. Msgr. Msgr. Most Rev. Rev. Pastor Sister Father Brother Deacon Rabbi Governor Senator Congressman Assemblyman Assemblywoman Lt. Capt. Major Cmdr. Col. Admiral General Ambassador Sir Madam Sir/Madam Elder Sr. Sheriff Mayor Inspector Min. Minister Chief Messrs. Sgt. Mr. & Mrs. Dr. & Mrs. Dean Legislator Detective Sgt. & Mrs. Det. & Mrs. Rev. & Mrs. Deputy Chief Hon. & Mrs. Ms Det. PO Chaplain Rev. Dr. Principal County Executive Councilwoman Suffolk County Treasurer County Legislator Supervisor Islip Town Supervisor Executive Town Clerk Town Councilman Councilman , Sr. Rev. Fr. . Chef The Mr. and Mrs.	*
First name:		*
Last name:		*
Country:	USA ESS England United States	*
Address lines:		*
City:		*
State:	<Please Select> AA AB AE AK AL AP AR AS AZ BC CA CO CT CZ DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NL NH NJ NM NS NT NU NV NY OH OK ON OR PA PE PR PW QC RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT	*
ZIP:		*
Phone:		*
Email:		*
Payment Information
Cardholder's Name:		*
Credit Card Number:		*
Card Type:	Visa American Express Discover Maestro MasterCard	*
Valid From:	01 02 03 04 05 06 07 08 09 10 11 12  / 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018  (Maestro/Switch/Solo only)
Card Expiration:	01 02 03 04 05 06 07 08 09 10 11 12  / 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032	*
Issue Number:	(Maestro/Switch/Solo only)
Card Security Code:		*
	Note: The Card Security Code is not required for Maestro, Switch and Solo cards.
Matching Gifts
	My company will match my gift
Company:		*
Tribute Information
Type:	In Memory Of In Honor Of	*
Name:		*
First name:
Last name:		*
	Mail a letter on my behalf to	*