Registration Request for My Kid's Chart

Registration Request for My Kid's Chart
Parent / Guardian Name:*

First NameLast Name
Email Address:*
example@example.com
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
List the names and dates of birth for all of your children:*
Once your account is created, you will receive an email with a temporary password that is active for 1 week. You must sign into the portal to complete your account set-up. Be sure to verify that your name appears correct and that the names of the patients you have requested access to appear on the screen.

Please be aware that when a patient turns 18, the record for that patient automatically becomes private. Messages can still be sent in regard to the patient, but the information in the chart cannot be viewed. After the patient is 18, he or she may grant permission to a parent or guardian to have access to the chart by completing and signing a release form. This permission can be revoked at any time at the patient's request or at the physician's discretion.
I hereby avow that I am the authorized legal guardian for the aforementioned patients and give permission for Denville Pediatrics to enroll them in the patient portal:*

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