Register for the Public Cord Blood Bank

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:

*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.

*First name:

*Family name:

*Father’s ethnic origin:

*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:

*Name of the attending physician:

*I would also like to register in the Public Mothers’ Milk Bank:

Yes

No

I have read the Consent to Cord Blood Donation.