Print and Post Form
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Healesville Hospital Logo
Yes, I would like to help Healesville Hospital
Contact Us

• Please print and post this coupon (and donation, if applicable) to:
Martin Wilkinson, Campus Manager / Director of Nursing
Healesville and District Hospital, P O Box 1247, Healesville 3777
    or
  • Email your donation details or enquiries to:
    martin.wilkinson@pjc.org.au
Please accept my gift of:
Mr/Mrs/Miss/Ms
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Address
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Day time phone line
Email
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Payment Details
tickbox My cheque/money order is enclosed.
Please make cheques payable to Healesville and District Hospital.
tickbox Please debit the amount indicated below to my:
 Bankcard
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Mastercard
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Visa
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Account No.
 Credit Card Number
Name on Credit Card (print)
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Signature line Expiry Date line /
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A receipt will be sent promptly.
Please send more information about:
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 How I can include Healesville and District Hospital in my Will
tickbox Making an in-kind donation
tickbox Sponsorship of hospital programs/research
tickbox How my group can fundraise for you
Thank You
Healesville and District Hospital
377 Maroondah Highway, Healesville 3777
Telephone: 03 5962 4300Fax: 5962 2226