Patient Portal Access Form Parent/Legal Guardian/Patient Request to access Patient PortalUser Requesting AccessNotifications (including initial sign in link) can be sent to one of the below choices: Text Email Text Phone #Email By signing below, I certify that I am the parent or legal guardian of the patient(s) listed below and I understand that my portal access (other than messaging and family account balance) will be revoked once the patient is 18 years old. Signature of User Requesting Access:Name First Last DoB MM slash DD slash YYYY Relation to userName First Last DoB MM slash DD slash YYYY Relation to userName First Last DoB MM slash DD slash YYYY Relation to userName First Last DoB MM slash DD slash YYYY Relation to userName First Last DoB MM slash DD slash YYYY Relation to user Δ
