Adult Patient Portal Enrollment Form

1
Name* This field is required.
First Name
MI
Last Name
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2
Date of Birth* This field is required.
MM/DD/YYYY
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3
Phone Number* This field is required.
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4
Phone Number Type:* This field is required.
Cell
Home
Work
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5
Preferred Email Address for Portal Account* This field is required.
example@example.com
Confirm Email
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6
Patient Portal Features

Send and receive messages from your child’s doctor or support staff.

View immunizations records (administered by EMG), laboratory results, referrals, and much more.

Request and view upcoming appointments.
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7
Healow App

Access your and your family’s health information with a single app.

Book your appointment fast at your convenience.

Personalize and manage your medications all in one place.

Your complete health record at your finger tips.

Automated reminders for upcoming appointments & easy check-in.

Set your health goals and track them easily using trackers.

Receive interactive health alerts and messages from your doctor.

Download the Healow app from the Google Play Store or the Apple App Store and find us using our unique practice code: JCGIBA
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8
Account Authorization Policy

By completing and signing this form you agree to access and create a portal account upon receipt of username and password. Your doctor will be sending results and health information to your portal account.
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9
Account Authorization Agreement* This field is required.
By checking this box, I acknowledge that I have read and hereby agree with the terms and conditions in the Account Authorization Policy.
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10
MyEMGChart Consent

Edinger Medical Group is offering this HIPAA compliant MyEMGChart (patient portal) as a courtesy to our patients. It is an optional service that we reserve the right to suspend or terminate at any time. We will alert you to any changes as promptly as possible. This consent is intended to inform you of the facts and risks surrounding the use of the web portal. By acknowledging below you have confirmed that you have read, understand and agree to comply with our procedures and guidelines for using MyEMGChart. You also agree not to hold Edinger Medical Group or any of our staff liable for network infractions beyond their control.

MyEMGChart (patient portal) has a tunnel connection with our office that uses encryption to keep unauthorized persons from being able to access and read health information or communications from us. To help ensure that this system remains secure, we need to have your current PRIVATE email address and inform our office if it ever changes. Keep your MyEMGChart username and password secure so only you, or someone authorized by you (example, an alternate parent/guardian), can gain access to your child’s information. If you think someone has learned your password, immediately go to the portal site and change it. It is your responsibility to protect your password and login.
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11
MyEMGChart Consent Agreement* This field is required.
By checking this box, I acknowledge that I have read and hereby agree with the terms and conditions in the MyEMGChart Consent.
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12
Signature* This field is required.
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13
Signer's Name* This field is required.
First Name
Last Name
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