Process my membership donation through Stripe

Enter your details below and choose a donation of either $500 or $1000. Your payment will be processed directly on Stripe's' server and you can select to pay via Credit or Debit card. We do not store your card information.

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Your Name *

First

Last

Your medical title *

Eg. MD, Dr, FAAP, etc

Your area of practice *

Eg; OBGYN, Ped, etc

Your preferred Email *

Where do you live? *

1000 Club Donation Amount *

Please select a donation above

Total

$0.00

Do you want to Donate anonymously

If you select no, we may post details of your donation to thank you on social media

Stripe Credit Card *