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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.

 
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Donation Information
$ 50.00
$ 100.00
$ 250.00
$ 500.00
$ 1,000.00
$    
Additional Information
Billing Information
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*
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*
*
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Payment Information
*
*
  *
 /  (Maestro/Switch/Solo only)
*
 (Maestro/Switch/Solo only)
help *
  Note: The Card Security Code is not required for Maestro, Switch and Solo cards.
Matching Gifts
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Donation Information
$ 15.00
$ 25.00
$ 50.00
$ 100.00
$ 250.00
$ 500.00
$ 1,000.00
Additional Information
Billing Information
*
*
*
*
*
*
*
*
*
*
Payment Information
*
*
  *
 /  (Maestro/Switch/Solo only)
*
 (Maestro/Switch/Solo only)
help *
  Note: The Card Security Code is not required for Maestro, Switch and Solo cards.
Matching Gifts
Tribute Information