Childrens Connect -

Parent/Legal Guardian/Adult Patient Information

First Name:

Middle Initial:

Last Name:

SSN:

DOB(xx/xx/xxxx):

Address:

City:

State:

Zip Code:

Home Phone(xxx-xxx-xxxx):

Email Address:

Primary Children’s Provider Office:

Requesting Access for:

Existing AccountNew AccountSelf

Child Information

Child's First Name:

Child's Middle Initial:

Child's Last Name:

DOB(xx/xx/xxxx):

Relationship to child:

Birth ParentStep-ParentLegal Guardian*Adoptive Parent

*Legal Guardianship papers must be on file before access can be granted

Additional Child Information

Child's First Name:

Child's Middle Initial:

Child's Last Name:

DOB(xx/xx/xxxx):

Relationship to child:

Birth ParentStep-ParentLegal Guardian*Adoptive Parent

*Legal Guardianship papers must be on file before access can be granted

Additional Child Information

Child's First Name:

Child's Middle Initial:

Child's Last Name:

DOB(xx/xx/xxxx):

Relationship to child:

Birth ParentStep-ParentLegal Guardian*Adoptive Parent

*Legal Guardianship papers must be on file before access can be granted

PLEASE READ AND CERTIFY

I am the birth/adoptive parent or legal guardian of the child and/or children listed above and that all information I have provided is correct. By signing this form, I acknowledge that I have read and understand this Children’s Connect Consent Form and I agree to its terms and conditions. I hereby request access to my child and/or children’s online health record.

I Certify:

Yes

Children's Connect Activation Code Request & Consent

Parent/Legal Guardian/Adult Patient Information

Child Information

Additional Child Information

Additional Child Information

PLEASE READ AND CERTIFY