Secure Waiver to enroll in MyChart

MyChart Features:

Access to letters, health forms, lab results and growth charts
Request a refill of medication
Pay bills online
Review visit summaries
View upcoming appointments
Send NON URGENT messages to our front desk and triage nurses
View tip and informational sheets
Update your medical demographics.
Make changes to your address, insurance and contact information
Update family medical history, current health issues, allergies and medications

Patient's Name

Date of Birth

Pediatrician

Patient's Name

Date of Birth

Pediatrician

Patient's Name

Date of Birth

Pediatrician

Patient's Name

Date of Birth

Pediatrician

Parent/Guardian accessing MyChart: (for patients under 13):

Name

Relationship

Date of Birth

Zip Code

Email Address

Parent/Guardian accessing MyChart: (for patients 13+):

Email address for any child 13+: Please note all patients 13 and older need to have their own MyChart account using their own email address to be able to access features such as virtual visits.

Email Address for Child 13+

I give permission to my Parent(s) listed below
to access MyChart

Initials

Please check and initial that you understand the following:

Mychart should NOT be used for medical emergencies and/or urgent medical matters

Online scheduling is not a feature our office offers at this time

When sending a message to your Pediatrician, this message will reviewed by a nurse and not your Pediatrician. A response will be returned within 72 hours by a triage nurse.

Messages will be responded to within 2-5 business days. You should call the office if you do not hear back through MyChart

MyChart does not contain a patient’s whole medical record

Printed Name

Date

Your information will be encrypted.