1 888 666.HEMA (4362)
Français
Donors
Blood
Plasma
Stem cells
Cord blood
Human tissues
Mother's milk
Volunteers
Get involved
How to participate?
Join as a volunteer
Blood drive results
Recognition program
Health professionals
Blood
Stem cells
Human tissues
Mother's milk
Français
Donors
Blood
Plasma
Stem cells
Cord blood
Human tissues
Mother's milk
Volunteers
Get involved
How to participate?
Join as a volunteer
Blood drive results
Recognition program
Health professionals
Blood
Stem cells
Human tissues
Mother's milk
Global Search
Search
Share
Facebook
Twitter
Stem cells
Stem cell donors
Umbilical blood donors
Who Can Donate Umbilical Cord Blood?
Steps from registration to donation
How to register?
Registration form
Health professionals
Learn more
Register for the Public Cord Blood Bank
Volunteer form
*
Required field
Baby’s mother
Please enter your first and last names as they appear on your health insurance card from the RAMQ.
*
First name:
*
Family name:
*
Date of birth:
*
Your ethnic origin:
Arab
Central Asian
North Asian
Northeast Asian
South Asian
Southeast Asian
Caucasian (White)
Chinese
African Black
Caribbean Black
Black - other
Filipino
First Nations
Hispanic
Inuit
Ashkenazi Jew
Sephardic Jew
Métis
Pacific Islander
Other
Address
*
No.:
*
Street:
Apt.:
*
City:
Province:
Québec
*
Postal code:
*
Telephone (home):
Telephone (work):
ext.
Cell. phone:
*
Email address:
Are you moving?
Yes
No
If yes, please fill out our change of address form
by clicking here
.
*
Baby’s father
*
First name:
*
Family name:
*
Father’s ethnic origin:
Arab
Central Asian
North Asian
Northeast Asian
South Asian
Southeast Asian
Caucasian (White)
Chinese
African Black
Caribbean Black
Black - other
Filipino
First Nations
Hispanic
Inuit
Ashkenazi Jew
Sephardic Jew
Métis
Pacific Islander
Other
*
Information about the pregnancy
*
Are you pregnant with more than one baby (e.g., twins, triplets...)?
Yes
No
*
Is a Caesarean planned?
Yes
No
*
Expected delivery date:
*
Hospital where you will be giving birth:
Choose...
St. Mary’s Hospital
CHU Sainte-Justine Mother and Child University Hospital Center
McGill University Health Centre (Glen site)
Centre hospitalier de l’Université Laval (CHUL)
Hôpital de la Cité-de-la-Santé de Laval
LaSalle General Hospital
Hôpital du Sacré-Coeur de Montréal
Lakeshore General Hospital
Jewish General Hospital
Please specify:
*
Name of the attending physician:
Consent for registration in the Public Mothers’ Milk Bank
*
I would also like to register in the Public Mothers’ Milk Bank:
Yes
No
I have read the
Consent to Human Milk Donation
.
I,
acknowledge on
having read and understood the information contained in the registration form to the Public Mothers’ Milk Bank and the Consent to human milk donation. I have had the opportunity to ask a Héma-Québec representative all my questions and have received satisfactory answers.
I understand that it is important that I inform Héma-Québec of any changes in my health status.
I understand that Héma-Québec reserves the right to contact me, if necessary, for any medical reason related to my health, that of my child or that of the recipient.
I understand that if my donation does not qualify for the Public Bank, I can consent to donate it to support research projects approved by an ethics board.
*
If my donation does not qualify for banking, I would like it to be used for research on human milk:
Yes
No
I certify that the information provided is complete and accurate to the best of my knowledge.
*
CONSENT TO REGISTRATION IN THE PUBLIC CORD BLOOD BANK
I have read the
Consent to Cord Blood Donation
.
I,
acknowledge on
having read and understood the information regarding registration in the Public Cord Blood Bank and the Consent to Cord Blood Donation. I have had the opportunity to ask a Héma-Québec representative all my questions and have received satisfactory answers.
I understand that it is important that I inform Héma-Québec of any changes in my health status and notify Héma-Québec if my child develops an immune or blood disease.
I understand that Héma-Québec reserves the right to contact me, if necessary, for any medical reason related to my health, that of my child or that of the recipient.
I understand that if my donation does not qualify for the Public Cord Blood Bank, I can consent to donate it to support research projects approved by an ethics board.
*
If my donation does not qualify for banking, I would like it to be used for research on cord blood:
Yes
No
I certify that the information provided is complete and accurate to the best of my knowledge.
Homepage
Stem cells
Umbilical blood donors
Register for the Public Cord Blood Bank
Register for the Public Cord Blood Bank
Top