Proxy Access to MyChart Form: Age 13 & younger
Proxy Access to MyChart Form: Age 14 -17
Proxy Access to MyChart Form: Age 13 & younger, Proxy Access to MyChart Form: Age 14 -17
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mandatory fields
Recipient Role/Description
Name of Parent / Legal Guardian
Your First Name
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Your Last Name
*
Your Email Address
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Recipient Role/Description
Name of Parent / Legal Guardian
Deselect this option if Name of Parent / Legal Guardian is available
First Name
*
Last Name
*
Email
*
Recipient Role/Description
*** ENTER PATIENT FULL LEGAL NAME ***
Deselect this option if *** ENTER PATIENT FULL LEGAL NAME *** is available
First Name
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Last Name
*
Email
*
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