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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
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Stem cells
Stem cell donors
Who can donate stem cells?
If you are chosen: what to expect?
Steps to register
Registration form
Notify us of a change of address
Umbilical blood donors
Health professionals
Learn more
Join the Stem cell donor Registry
Step 1
Step 2
Step 3
Registration form
*
Required fields
Medical questionnaire
*
Are you between the ages of 18 and 35?
Yes
No
*
Date of birth:
*
Are you in good health?
Yes
No
*
Please indicate your height and weight.
m
feet
kg
lbs
*
Have you given blood before?
Yes
No
If so, in which year and city did you last give blood?
*
Has Héma-Québec, the Canadian Blood Services or a physician ever told you NOT to give blood?
Yes
No
If so, why?
*
Have you ever had one of the following conditions:
Cancer, not including successfully treated skin or cervical carcinoma
Yes
No
Start date of the illness:
Recovery date:
Symptoms experienced:
Insulin-dependent diabetes mellitus
Yes
No
Start date of the illness:
Recovery date:
Symptoms experienced:
Heart disease or heart surgery or heart valve transplant
Yes
No
Start date of the illness:
Recovery date:
Symptoms experienced:
Chronic lung diseases or asthma treated with steroids or causing an anaphylactic reaction
Yes
No
Start date of the illness:
Recovery date:
Symptoms experienced:
Ulcerative colitis (disregard non-ulcerative colitis)
Yes
No
Start date of the illness:
Recovery date:
Symptoms experienced:
Crohn's disease
Yes
No
Start date of the illness:
Recovery date:
Symptoms experienced:
Epilepsy requiring medication and/or seizure in the past 2 years
Yes
No
Start date of the illness:
Recovery date:
Symptoms experienced:
Rheumatoid arthritis
Yes
No
Start date of the illness:
Recovery date:
Symptoms experienced:
Ankylosing spondylitis
Yes
No
Start date of the illness:
Recovery date:
Symptoms experienced:
Neurological problems
Yes
No
Start date of the illness:
Recovery date:
Symptoms experienced:
Schizophrenia or bipolar disease
Yes
No
Start date of the illness:
Recovery date:
Symptoms experienced:
Anemia with continuing iron prescription or severe symptoms
Yes
No
Start date of the illness:
Recovery date:
Symptoms experienced:
Sickle-cell, aplastic or hemolytic anemia of genetic origin
Yes
No
Start date of the illness:
Recovery date:
Symptoms experienced:
Hepatitis B or C/positive test result for hepatitis or HIV
Yes
No
Start date of the illness:
Recovery date:
Symptoms experienced:
Creutzfeldt-Jakob in a close relative
Yes
No
Start date of the illness:
Recovery date:
Symptoms experienced:
I certify that the information provided is complete and accurate to the best of my knowledge.
I have read the
Guide for the Potential Donor
. I understand that by joining the Stem Cell Donor Registry, I agree to give stem cells to anyone in need. I realize that if compatibility is established between me and a recipient, a subsequent decision to withdraw from the process could have deadly consequences for the patient.
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