Doctors Day Gift Form - North Carolina Medical Society

Honor Your Favorite Physician on Doctors' Day!

Show your appreciation with a gift to the NCMS Foundation! Questions? Please contact Belinda McKoy, bmckoy@ncmedsoc.org or (919) 865-5241.

Doctors' Day Donation Information

Make a $10 gift to send one card or make a larger gift to the Foundation by filling in your own amount in the field below.

Amount:

$ 10.00

Other

Doctors' Day Gift Details

Anonymous:

Check here to make this donation anonymously.

Physician Honoree's Name:

*Check to send e-card*

Billing Information

Title:

First name:

Last name:

Country:

Address lines:

City:

State:

ZIP:

Phone:

Email:

Payment Information

PLEASE NOTE: IT MAY TAKE SEVERAL SECONDS FOR YOUR TRANSACTION TO PROCESS; DO NOT CLICK ON THE DONATE BUTTON MORE THAN ONCE. Although it may seem as though your submission has lagged, you should see a confirmation screen momentarily and you will receive a confirmation email once the donation has processed.

Cardholder's Name:

Credit Card Number:

Card Type:

Card Expiration:

Card Security Code:

Additional Security

This is a security measure to help prevent fraud.