Donation Form | ARdocsCare

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With your support, ARdocsCare will be a strong and clear voice for sensible health care reform. To be successful we need your participation and your financial support. Would you be willing to consider partnering with ARdocsCare with a contribution of $2,500, $1,000, $500 or any other amount?

Your gift will allow us to:
- have the necessary tools to communicate with our congressional delegation
- maintain this website that provides tools and information for doctors to use in communicating with policy makers
- recruit additional physicians to join the organization
- publicize our message to our delegation as well as other physicians and the greater public

We cannot emphasize enough the importance of having substantial financial support as soon as possible in order to make an impact on the current health care debate.

Agreement

I Agree: *

Yes, I agree with and endorse the principles of ARdocsCare

I Authorize: *

Please check one of the below:

I authorize the inclusion of my name as a supporter of ARdocsCare on any petition or correspondence that is submitted to the Arkansas Congressional Delegation or the public.

I agree with and endorse the principles of ARdocsCare but do not want my name included on correspondence with the Arkansas Delegation or in the public domain.

Your Initials: *

Please enter in your initials to confirm and authorize your endorsement.

Contribution

YES, I will support ARdocsCare with a contribution of:

My Contribution:

$5,000

$2,500

$1,000

$500

$250

Other

Other:

If you wish to donate a different amount, please enter above.

Additional Support

I would also like to help ARdocsCare in the following ways:

Please check one of the below:

Help:

Make phone calls to the Arkansas Congressional Delegation

Send a letter to the Arkansas Congressional Delegation

Help recruit other physicians to join the organization

Write a letter to the editor and/or op-ed

Raise additional funds for ARdocsCare

My Information

Name: *

Address: *

City: *

State: *

Zip Code: *

Type of Physician: *

Name of Practice/Facility:

Work Phone:

Cell Phone:

Email address: *

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