Online Donation Form

NOTE: When filling out payment information on the next form, please enter the credit card's expiration date without the slash (mmyy). If you have problems paying via credit card online please call the Foundation office at (919) 784-4424. Thank you!

Thank you for your interest in donating to the Rex Healthcare Foundation. Please fill out the form below and then proceed to fill out payment and billing information after clicking "Submit" at the bottom.


Donation Information

* Indicates required information
Please designate my donation as follows:
(Check all that apply) * 

If Other, please specify:

Please tell us how you heard about us:
(Check all that apply) * 

If Other, please specify:

(As it will be displayed in donor listings) 
If you would like to make a tribute to someone please provide his/her full name: 
Tribute type: 
If you would like for us to mail a letter to someone on your behalf please provide their name, address, city, state and zip code: 
Check any/all that apply: 

Payment Information

If Other, please specify:


Once you click submit you will be directed to a secure payment site.
(You will need to disable your browser's Pop-up blocker for the payment window to open.)

Rex Healthcare Foundation | 2500 Blue Ridge Rd, Ste 325 | Raleigh, NC 27607
(919) 784-4424 |

Any information you exchange with this site is protected from view by other Internet users. Any e-mail addresses you enter may be used to send you a verification message, but such addresses will not be used to request personal information of any type nor will any contact details be shared with other companies. Rex Healthcare Foundation uses industry-standard encryption technologies when transferring and receiving payment data. If you have questions, please contact us for more information at (919) 784-4424.