#ThankYouNHS! Donate today to help our hospitals.

I'd like to help Imperial Health Charity provide extra support to patients, families and NHS staff:

£100 £50

£25

My chosen amount of £

I would like to pay by:

Your details

Title

First name

Address cheque (enclosed with this donation form)

Mastercard/Visa (delete as appropriate)

Please contact me about my donation

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Expiry date /

Gift Aid

For every £1 you donate, Gift Aid allows us to claim 25p from HM Revenue & Customs, increasing the value of your donation at no extra cost to you. Please tick the box below:

Yes, I would like Imperial Health Charity to claim Gift Aid on any donations I make in the future or have made in the past four years. I am a UK taxpayer and I understand that if I pay less Income Tax and/or Capital Gains Tax in the current tax year than the amount of Gift Aid claimed on all my donations it is my responsibility to pay any difference.

Signature Date

Yes, I would like to hear from Imperial Health Charity about the impact my gift has made as well as other news, events and opportunities to support their work. (You can opt out of communications at any time by emailing fundraising@imperialcharity.org.uk. For more information, go to imperialcharity.org.uk/privacy).

Yes, I would like to receive more information about how I can leave a gift in my will to support Imperial Health Charity.

Please make sure all the fields above are completed and return this form to: Imperial Health Charity, 178-180 Edgware Road, London, W2 2DS

A registered charity, no. 1166084