Join as an apheresis donor (red blood cells, plasma and platelets)

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Identification
Title: Mr. Ms. Family name: First name: Date of birth: Email address: No.: Street: Apt.: City: Province: Postal code: Please provide at least one telephone number Telephone (home): Telephone (work): Cell. phone:
*Are you already a Héma-Québec blood donor?
Yes What is your donor number? What is your blood type? No
*Where did you fill out this form?
On the Héma-Québec Web site At a blood drive In which city/town (e.g., Montréal)? At which location (e.g., McGill University)?
*Who asked you to fill out this form?
Volunteer Héma-Québec staff member Ambassador donor: Other (friend, family member, co-worker, etc.), please specify:
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