OHMB Intake Survey

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OHMB Intake Survey

By completing this form you consent to be contacted by the Ottawa Human Milk Bank and to keep this information for tracking donations from our region. This information will not be shared outside of OHMB

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How did you hear about The Ottawa Human Milk Bank?

Facebook, twitter, Instagram or other social media

Care Provider, Doctor, Midwife, Hospital

Friend

Other:

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Are you presently pregnant?

Yes

No

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How many weeks pregnant are you now?

First trimester (4-16 weeks)

Second Trimester (17-28 weeks)

Third Trimester (More than 28 weeks)

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