Authorization for Parental Access to My Kid's Chart Patient Portal and Permission to speak with
Ages 18 and older
Patient Name
First Name
Last Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Today's date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I AUTHORIZE the following Parents/Guardians to have access to my patient portal
First Name
Last Name
First Name
Last Name
Signature
I REVOKE the following Parents/Guardians to have access to my patient portal
First Name
Last Name
Signature
Submit
Should be Empty: