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If you would like access to your child or another adult s MyChart information please ask your clinic for the appropriate forms or download them from www. Your Information All sections required please print clearly. Name last first middle initial Date of Birth Last 4 Digits of Social Security Number Email Street Address City Phone Number Primary Physician Patient s full SSN must be on file with DMG to activate a MyChart account State Zip MyChart Terms and Agreement I understand that MyChart is ...

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