Patient Portal (Individual)

My Kids' Chart Patient Portal

Bloom Pediatrics • 2055 E 14 Mile Road, Birmingham, MI 48009 • (248) 645-1740
Patients

List the name and date of birth for each child in your family who is a patient.
How many children in the family are patients?
Patient 1 Name*
Patient 1 Date of Birth*

MonthDayYear
Date
Patient 2 Name
Patient 2 Date of Birth

MonthDayYear
Date
Patient 3 Name
Patient 3 Date of Birth

MonthDayYear
Date
Patient 4 Name
Patient 4 Date of Birth

MonthDayYear
Date
Patient 5 Name
Patient 5 Date of Birth

MonthDayYear
Date
Patient 6 Name
Patient 6 Date of Birth

MonthDayYear
Date
Patient Portal Access

Access to records is available for all children under 18 years of age. When a patient turns 18 years old in the State of Michigan, by law, their record automatically becomes private. They may grant permission to a parent or guardian to access their chart by signing an additional release form.

Please list the name and email of the parent/guardian that would like access to the patient portal.
Parent/Guardian Name*

First NameLast Name
Email Address*
example@example.com
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

My Kids' Chart Patient Portal