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