Membership Form

We want to thank you for your incredible support. By including a gift to Brigham and Women’s Hospital in your future plans, you have made the delivery of medical breakthroughs part of your personal legacy.

The information you provide below about your legacy gift for the Brigham will ensure that our records are accurate, and that we use your gift in the way that you intend. This is not a binding legal document, and your information will be kept confidential. If you have any questions, please contact Kathleen S. Duffy, at 617 424 4326 or