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Title
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Mr.
Mrs.
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Doctor
Miss
Mx
Gender
First name
Last name
Job title
Company
Country
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Canada
Address
City
Province
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Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
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Nunavut
Ontario
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Yukon
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Phone
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Additional information
Personal information
Are you an Aboriginal?
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yes
no
Please select the highest education program successfully completed
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Elementary
High School
College
University
Please select the mother’s age group during childbirth
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0 to 19
20 to 25
26 to 30
31 to 35
35 and +
Household informations
What is your family income?
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Less than $35 000
$35 000 to $50 000
$50 000 to $100 000
$100 000 to $200 000
more than $200 000
Have your family immigrated less than 5 years ago?
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yes
no
Are you a single parent?
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yes
no
Please select the language spoken at home
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French
English
Other
Pregnancy and childbirth
Is your baby currently hospitalized?
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No
Yes
Date of last birth
Number of gestation weeks (at birth)
Is it a multiple pregnancy? (ex: twins, triplets...)
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Yes
No
Baby's sex
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Girl(s)
Boy(s)
Boy & Girl
Have you lost a premature infant?
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yes
no
How many children under 6 years old do you have, excluding your newborn children?
Discovery of the organization
How did you hear about Préma-Québec?
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Already in contact with the organization
Hospital staff
Referral from a friend/family
Referred by another beneficiary
Posters
Media
Internet search
Other
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Organization's registration number:
88791 9504 RR0001
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