Your browser does not support JavaScript!
This form cannot automatically check that you have submitted all of the required fields without JavaScript.
Please be sure to submit all required fields (marked with stars).

Salem Regional Medical Center

Hospital Donations

Salem Regional Medical Center welcomes online donations from members of our community. There are various needs and programs that continually need support and funding. Please accept our thanks for your consideration and donations. To donate please scroll down the page and read the short directions.
All information will be kept secure and confidential. For more information on membership or to make a donation you may call our business office. We are a non-profit organization.

We want you to know that our healthcare facility carefully uses your donation for important needs of the hospital. You may donate by providing your credit card information in below fields.

All payments are via secure server. Thank you for your support.
* Name
As It Appears On Donor's Credit Card or Checking Account.
* Billing Address
Address Where Your Credit Card Statements Are Mailed.
* City, State, Zip Code
Please Include Your City, State and Five Digit Zip Code.
* Phone
555-555-5555
* Your Email Address
Please Provide An E-mail Address.
* Amount of Your Donation
Please Specify How Much You Are Donating. Please Use Dollars and Cents.
* Credit Card Type
Select If You Are Paying By Credit Card.
* Credit Card Number
Input The 16 Digit Number Just As It Appears On Card.
* Credit Card Expiration Date
mm/yy
* CV3 Code
3-digit code located on the back of your credit card.
A memorial or tribute card can be sent (The amount will not be revelaed on the card)
  In Memory of
  In Honor of
Send the acknowledgement card to:
  Name
  Address
  City, State, Zip
  Your name(s) as you would like it to appear on the card