Register for the Public Mothers’ Milk Bank

Thank you for the generosity you are showing to those in need of mother’s milk.

Please note that only one registration per six-month period is allowed. If you would like to correct an answer provided during your last registration, contact our team by email at mothersmilk@hema-quebec.qc.ca or by phone at 1-800-565-6635, poste 5253.

The following up on new registrations to the Public Mothers’ Milk Bank can take up to two weeks. Be sure to consult the Who can donate? section before registering.

Do you usually have surplus milk?

Yes

** Since your baby is the priority, you must have surplus milk to be able to donate to the Public Mother’s Milk Bank. If you would like more information, contact us:
By phone at 1 800 565-6635, extension 5253
By email at lait.maternel@hema-quebec.qc.ca
Thank you for your interest.

Do you take medications?

Yes

*Please check the list of acceptable medications to ensure that you are eligible to donate breast milk

If you are taking a medication on the list, you can donate your surplus milk. Are you taking a medication not on the list?

Yes

** Taking medications that are not on the lists excludes you from giving breast milk. If you would like more information, contact us:
By phone at 1 800 565-6635, extension 5253
By email at lait.maternel@hema-quebec.qc.ca
Thank you for your interest.

Are you taking natural products, such as:

Herbal supplements;
Herbal teas containing fenugreek (for example, Mother’s MilkTM herbal tea); or
Homeopathic products?

Yes

** Taking a supplement or natural product excludes you from donating breast milk. If you would like more information, contact us:
By phone at 1 800 565-6635, extension 5253
By email at lait.maternel@hema-quebec.qc.ca
Thank you for your interest.

Volunteer form

*Required field

Personal information

Please enter your first and last names as they appear on your health insurance card from the RAMQ.

*First name:

*Family name:

*Email address:

We have received your first registration. You can register again in six months. If you would like to correct an answer provided during your last registration, contact our team by email at mothersmilk@hema-quebec.qc.ca or by phone at 1-800-565-6635, ext. 5253.

*Date of birth:

Address

*No.:

*Street:

Apt.:

*City:

Province:

Québec

*Postal code:

*Telephone (home):

Telephone (work):

ext.

Cell. phone:

Are you moving?

Yes

If yes, please fill out our change of address form by clicking here.

*Baby’s birth date

*Is your baby hospitalized?

Yes

If so, at which hospital?

Which Héma-Québec donor centre do you plan to visit for your blood samples?

Which of the following drop-off points is closest to your home and within a one-hour drive?

You cannot register because there is no drop-off point near your home. Thank you for your interest.

*Best time to call you

Please indicate your preference to receive the follow-up call. Please note that this call may occur within the next 6 weeks:

Monday:

Between 9 a.m. and noon

Between 1 p.m. and 4 p.m.

Tuesday:

Between 9 a.m. and noon

Between 1 p.m. and 4 p.m.

Wednesday:

Between 9 a.m. and noon

Between 1 p.m. and 4 p.m.

Thursday:

Between 9 a.m. and noon

Between 1 p.m. and 4 p.m.

Friday:

Between 9 a.m. and noon

Between 1 p.m. and 4 p.m.

*CONSENT FOR REGISTRATION IN THE PUBLIC MOTHERS’ MILK BANK

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

I understand that, as part of my registration, I will have to travel to a Héma-Québec donor centre to provide a blood sample. I also understand that, if I qualify to donate, only those donations collected after qualification will be accepted. I understand that, as part of my registration, I will have to travel to a Héma-Québec donor centre to provide a blood sample. I also understand that, if I qualify to donate, only those donations collected after qualification will be accepted. I will need to bring my milk to the designated drop-off point, which cannot be more than a one-hour drive from my home.

I certify that the information provided is complete and accurate to the best of my knowledge.

You cannot register because there is no drop-off point near your home. Thank you for your interest.

Register for the Public Mothers’ Milk Bank

Personal information

Address

*Baby’s birth date

*Best time to call you

*CONSENT FOR REGISTRATION IN THE PUBLIC MOTHERS’ MILK BANK

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