Name: | DOB: | MRN: | PCP:

MyChart Parent/Guardian Sign Up Form

Please fill out the information requested below to create a parent MyChart login. Then, continue to the Patient Information section to add information about all of your children (up to 5).

To view all health records with one MyChart account, click the "Additional Sibling" links to add information for up to five children. If you have a sixth child (or more) that you would like to add to MyChart, please contact your PediaTrust practice.

If your child is 12 years and older, please remember to submit a signed authorization form to your PediaTrust practice: MyChart Authorization Forms

Please Note: If you are a patient 18 years or older and would like to request access to MyChart, please complete the MyChart Patient Sign Up form.

*These items are required.

Parent/Guardian Information:

xxx-xxx-xxxx

Patient(s) Information:

Note: Click the "Additional Sibling" links to add information for up to five children. If you have six or more children that you would like to add to MyChart, please contact your PediaTrust practice.
MM/DD/YYYY
Additional Sibling (Optional)

Enter Additional Sibling Information:

MM/DD/YYYY
Enter a different address
Additional Sibling (Optional)

Enter Additional Sibling Information:

MM/DD/YYYY
Enter a different address
Additional Sibling (Optional)

Enter Additional Sibling Information:

MM/DD/YYYY
Enter a different address
Additional Sibling (Optional)

Enter Additional Sibling Information:

MM/DD/YYYY
Enter a different address

I certify that I am the parent or legal guardian of the child listed above and that all information I have provided is correct. I hereby request access to my child's online record. This authorization is valid until it is revoked or otherwise expires.

If your child is 12 years and older, a signed authorization form for proxy access is required. Please visit the Authorization Form page to fill out the correct forms.