Permission to Access Portal
By completing this form you, as an 18 year old and over patient is granting portal viewing privileges to the parent/guardian listed on this form. Please note that a confirmation email will be sent to the patient's email address provided. It is considered a privacy violation and criminal offense to falsify access when it has not been granted by the patient. This form is to be filled in ONLY by the patient granting access. Thank you.
Patient's Date of Birth
Name of Parent or Guardian Patient Granting Access
Email Address Used by Parent/Guardian to Access Portal
Should be Empty: