MyChart Activation Code Request for Adolescent

To request an account for an adolescent patient, please complete the form below. We will contact you by phone or email if we have any questions regarding the information provided.

Step 1 | TELL US ABOUT YOU

Today's Date:

First Name:

Middle Initial:

Last Name:

Your Date of Birth:

Street Address:

City:

State:

Zip Code:

Mobile Phone (xxx-xxx-xxxx):

Email Address:

Step 2 | CHILD/PATIENT INFORMATION:

Patient's First Name:

Patient's Middle Initial:

Patient's Last Name:

Sex Assigned at Birth:

Patient's Email:

Patient's Date of Birth:

Your relationship to the child:

If other, please specify:

CERTIFICATION:

I certify that I have the legal right to this minor's record and the information I have provided is accurate.

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