Donor Docs Registration

Doctor Name

Practice Name

Practice Street Address

Practice City

Practice Zip Code

Practice County
—Please choose an option—AlamanceAlexanderAlleghanyAnsonAsheAveryBeaufortBertieBladenBrunswickBuncombeBurkeCabarrusCaldwellCamdenCarteretCaswellCatawbaChathamCherokeeChowanClayClevelandColumbusCravenCumberlandCurrituckDareDavidsonDavieDuplinDurhamEdgecombeForsythFranklinGastonGatesGrahamGranvilleGreeneGuilfordHalifaxHarnettHaywoodHendersonHertfordHokeHydeIredellJacksonJohnstonJonesLeeLenoirLincolnMaconMadisonMartinMcDowellMecklenburgMitchellMontgomeryMooreNashNew HanoverNorthamptonOnslowOrangePamlicoPasquotankPenderPerquimansPersonPittPolkRandolphRichmondRobesonRockinghamRowanRutherfordSampsonScotlandStanlyStokesSurrySwainTransylvaniaTyrrellUnionVanceWakeWarrenWashingtonWataugaWayneWilkesWilsonYadkinYancey

Contact person to make arrangements / appointments

You or your contact's email address

I wish to donate:
3 free eye exams and 3 pairs of glasses, if neededI will volunteer to read retinal images for PBNC's retinal programI do not wish to donate services at this time

Please make my donated services available to the following group(s):
Children in Preschool - 12th gradeAdults identified through PBNC screening programsPatients from counties surrounding mine (if no donations are available in their own county)

I do not wish to donate exams or glasses, but instead, I would like to contribute financially by:
Mailing a check to PBNC 4011 Westchase Blvd., Suite 225 Raleigh, NC 27607Contact me over the phone to accept a credit card donation from meI do not wish to donate financially at this time

Acknowledgement on promotional materials:
Yes, please list me as a donating doctor on the PBNC website and social media platformsNo, please do not list me in any promotional materials

Please type your name to serve as your digital signature.