Dear our friend

 Thank you for your interest in helping the Alliance Health Clinic. Please print and complete this form, make your check  payable to "Alliance Health Clinic" and mail it along with your payment to: Alliance Health Clinic - 5952 El Cajon Blvd San Diego CA 92115.

    Gift Amount* $   

   Please tell us where to direct this gift.

           The Alliance Health Clinic as a whole for its greatest needs

           Clinical activities, such as special equipment or tests

           Patients’ education and well being

  Comments:

Personal Information:

Mr. Mrs. Ms. Dr.                        First Name                           MI                        Last Name

Street Address                                                                          City                       State                    Zip 

                              Home  Phone                                                             Work  Phone                                          

    
                    Please provide us with an e-mail address so we may contact you if we have any questions about your gift

                                                                        E-Mail

 * If you have any questions, please call us at 619-286-9052 ext 234