Outright Gift Contribution Form
In fiscal year 2003/2004, the Center provided more than 78,000 patient visits for children and their families who would not otherwise have had access to medical, dental and supportive services. For those who rely on us for their wide-ranging care needs, the Center is their family doctor and dentist, a place where they can come to receive timely and culturally appropriate free and low-cost services. Our clients are drawn predominantly from this district and impoverished surrounding neighborhoods of central and South Los Angeles.
Thank you for your generous donation.
To make your gift by mail, please make checks payable to:
Eisner Pediatric & Family Medical Center
And mail to:
Eisner Pediatric & Family Medical Center,
Attention: Carl E. Coan, President & CEO
1530 South Olive Street, Los Angeles, CA 90015.
To make your gift by fax using your credit card, please print, complete and fax the form below to:
Attention Leslie Villavicencio, EPFMC
Fax: (213) 746-9379
A confirmation and note of appreciation of your tax-deductable contribution to EPFMC will be mailed to you at the address you provide in this form.
| Full Name: | ________________________________________ (Associated with your credit card) |
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| Address: | ________________________________________ (Associated with your credit card) |
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| City: | ________________________________________ | |
| State: | ____________________ Zip: ________________ | |
| Home Phone: | ________________________________________ | |
| Business Phone: | ________________________________________ | |
| Email Address: | ________________________________________ | |
| Donation Amount: | ________________________________________ | |
| Please bill my: | Visa Mastercard |
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| Credit Card #: | ________________________ Exp: _____ / _____ | |
| Signature: | ________________________________________ | |
| I would prefer to make the transaction over the telephone. | ||
| Please call me at: | Work Home |
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Ph: (213) 746-1037, ext. 3474, or email lesliev@pedcenter.org