Donation Form - Poore Medical Clinic

Name*

First Last

Address (optional)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email (optional)

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Charitable Donation*

Please enter a number in dollar amount that you would like to donate. Thank you for supporting the Poore Medical Clinic! The Poore Medical Clinic is a 501(c)(3) non-profit organization. Donations are tax deductible to the extent allowed by law.