Registration – Nourri-Source Laurentides Community Clinics

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This registration form is designed to gather information to ensure that you are eligible for the services offered by the community clinic. Don't worry—if you aren't eligible, we will refer you to the best places for your needs/conditions.

The community clinic's services are offered free of charge to mothers in the Laurentian region. The service will be offered via Zoom by Marie-Audrey Lévesque, Lactation Consultant, IBCLC. The clinic takes place on Friday mornings, from 9:30 to 11:30. You will have a 30-minute appointment in this time slot.

Last name, first name *

Mother's date of birth *

YYYY

Street address (number, street, city, postal code) *

Email address *

Phone number (e.g., 450-444-5555) *

Do you have a Nourri-Source Laurentides breastfeeding godmother? *

Yes

Please select the best time slot for you. *

9:30 to 10:00 a.m.

10:00 to 10:30 a.m.

10:30 to 11:00 a.m.

11:00 to 11:30 a.m.

Whenever is fine

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