Parental Access Form

Child's Name

Child's Date of Birth dd/mm/yyyy

Request Access Request Access I hereby request access to View my child's medical information through the MyPortal patient portal.

Parent Email

Parent Phone (10 digits, no spaces)

As a parent, you can request your child to have access to his/her online medical record. As a parent, you can request your child to have access to his/her online medical record. I am hereby request that my child have access to their online medical record.

Child's Email

Please describe your relationship to the child Please describe your relationship to the child Birth Parent Adoptive parent Legal Guardian Other

If Other, Please Specify

Do you (parent/legal guardian) already have a MyPortal account? Do you (parent/legal guardian) already have a MyPortal account? Yes No Don't know

Parent Acknowledgement Parent Acknowledgement I have read and understand the requirements and procedures for accessing my child's medical record information online as provided on the page one of this document titled, Parental Access to the Online Medical Record of a Patient 12 to 17 years old. I certify that I am the birth parent or legal guardian of the child listed above and that all information is true to the best of my knowledge.

Parent Electronic Signature

Todays Date (dd/mm/yyyy)

Legal Signature Acceptance Legal Signature Acceptance I understand that checking this box constitutes a legal signature.

Patient Electronic Signature

Todays Date (dd/mm/yyyy)

Legal Signature Acceptance Legal Signature Acceptance I understand that checking this box constitutes a legal signature.