Sign up for MyChart

We need some information to grant you a MyChart account. After you submit this request, it may take up to a week for processing and verification. When you're approved, you will receive an email or a letter with your activation code and instructions on how to activate your MyChart account. If you have any questions, please contact us at (555)-555-5555.

Parents, guardians, and patients 13 and older can sign up for MyChart in person at an upcoming appointment or use this form to set up your account.

Helpful information:

• Enter YOUR information on this page. You are creating your MyChart account.
• Need to request access to a patient’s record? Look for the Request Proxy Access option on your home screen or in the MyChart menu to make this request.
• If you have any questions, please contact us at (555)-555-5555 or MyChartSupport@DoNotUse.DoNotUse.

Parents, guardians, and patients 13 and older can sign up for MyChart in person at an upcoming appointment or use this form to set up your account.

Helpful information:

• Enter YOUR information on this page. You are creating your MyChart account.
• Need to request access to a patient’s record? Look for the Request Proxy Access option on your home screen or in the MyChart menu to make this request.
• If you have any questions, please contact us at (555)-555-5555 or MyChartSupport@DoNotUse.DoNotUse.

Parents, guardians, and patients 13 and older can sign up for MyChart in person at an upcoming appointment or use this form to set up your account.

Helpful information:

• Enter YOUR information on this page. You are creating your MyChart account.
• Need to request access to a patient’s record? Look for the Request Proxy Access option on your home screen or in the MyChart menu to make this request.
• If you have any questions, please contact us at (555)-555-5555 or MyChartSupport@DoNotUse.DoNotUse.

Complete the missing information below to finish signing up for a MyChart account.

If you have any questions, please contact us at (555)-555-5555.