Patient and Family Emergency Services Fund

Dartmouth-Hitchcock’s Patient & Family Services Emergency Fund provides assistance to patients and their families who need help paying for medications, gas or transportation to and from medical appointments, or food while they are at DHMC.

If this is a gift in memory of or in honor of someone, please complete the Memorial and Honorary Gifts section at the bottom of this form.

Donation Information

Amount:

Gift of

$ 250.00

Gift of

$ 100.00

Gift of

$ 50.00

Gift of

$ 35.00

Other

Additional Information

Corporate:

This donation is on behalf of a company

Anonymous:

I prefer to make this donation anonymously

Comments:

I am a D-H/Geisel Employee:

Billing Information

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First name:

Last name:

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Payment Information

Fundraising activities on behalf of Mary Hitchcock Memorial Hospital (MHMH) is conducted by Dartmouth-Hitchcock Health, a 501(c)(3) recognized charity by the IRS (EIN#26-4812335), for the benefit of MHMH. Your gift will appear on your credit card statement as a payment to "D-HHealth Donation".

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Matching Gifts

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Memorial and Honorary Gifts

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Please notify the following person of my gift.