Logo of the Diane Hebert Foundation
    LA FONDATION DIANE HÉBERT


    for organ and tissue donation


Order form
Use this form to receive your organ and tissue donation sticker.
(Please note that this sticker has been specifically designed
 for use with the Quebec health insurance card)
 
Please, answer all the questions.

 

FORM TO COMPLETE
First name Last name
Address Apartment
City Province or state
Country Postal Code or Zip Code
Area code and phone number at home Area code and phone number at the office
Quantity of organ donor cards you need E-mail address


Save a life, recycle yourself.
Be an organ donor !

Click here to send E-mailSend E-mail to "La Fondation Diane Hébert"Logo of the Diane Hebert Foundation

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"La Fondation Diane Hébert"
132 rue Blainville est, Ste-Thérèse de Blainville (Québec) Canada, J7E 1M2
Tel.: (450) 971-1112  - Toll free # 1 877-971-1110