Free Clinic of Simi Valley Expo Donation Form – Give to the Free Clinic Today!

Donate Now!

* Indicates required field

Name *

First

Last

Address *

City *

State *

Zip Code *

Phone Number *

Cell Number *

Email *

Note From Donor (Tribute, Memorial, etc.): *

Donation Method *

Check Credit Card PayPal

Submit Donor Information

Payment Instructions

1. Complete and submit this online form above. Do not move on to payment without clicking "Submit Donor information"

2. Donation Options:

Donations by Credit Card - Select Amount:

A sampling of services that your donation provides:

Ten Childrens Fluoride Treatments

Two Pediatric Dental
Fillings

One Endometrial Biopsy to Screen for Cervical Cancer

Treatment of Two
Diabetic Patients for Vascular Ulcers

Five Treatments of Pre-Cancerous Skin Lesions

Three Periodontal Gum Surgeries

50 Well-Child Exams, including vaccinations

Find out more about this special group of donors, by clicking the button above.

Payments can be made via any credit card or by PayPal. Payments are processed through PayPal, but you are not required to have a PayPal account.

Donations by Check
Please make checks payable to: Free Clinic of Simi Valley (FCSV).
Please mail checks to: Free Clinic of Simi Valley, 2060 Tapo Street, Simi Valley, CA 93063 - Tax ID: 23-7108154