My Kids' Chart Patient Portal
Patients
Please list all children 18 and under
How many children in the family are patients?
*
Please Select
One
Two
Three
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Eight
Nine
Ten
Patient Name
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Date of Birth
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Date of Birth
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Date of Birth
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Date of Birth
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Patient Name
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Date of Birth
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Patient Name
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Date of Birth
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Patient Name
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Date of Birth
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Patient Name
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Date of Birth
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Patient Name
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Date of Birth
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Patient Name
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Date of Birth
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Patients 18 and above
Access to records is available for all children under 18 years of age. When a patient turns 18 years old in the State of Kentucky, 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 who would like access to the patient portal.
Parent/Guardian Name
*
First Name
Last Name
Relationship to Patient
*
Please select a log in method:
*
Phone Number
Email
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Would you like to add another Parent/Guardian
Yes
No
Parent/Guardian Name
*
First Name
Last Name
Relationship to Patient
*
Please select a log in method:
*
Phone Number
Email
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Signature
*
Date
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Month
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Day
Year
Date
Submit
Should be Empty: