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Patient portal consent form - Elmwood Pediatric Group 2026

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The document is a Patient Portal Consent Form from Elmwood Pediatric Group, outlining the terms for accessing a child's medical records through an online portal. It specifies that parents or legal guardians can access records for children aged 0-15, while patients aged 16 and older can create their own accounts or maintain access under a guardian's account. The form emphasizes that the portal is for non-urgent issues only and includes an acknowledgment section for patients and guardians to confirm understanding of the terms.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Patient Name, Date of Birth (DOB), and Age in the designated fields. This information is crucial for identifying your child’s medical records.
Specify the Primary Physician's name to ensure that all communications are directed appropriately.
Read through the terms and conditions carefully. Acknowledge your understanding by checking the box or signing where indicated.
For patients aged 16 and older, provide your signature in the required section. If the patient is under 16, a parent or legal guardian must sign instead.
Finally, enter the date of signing to complete the form. Ensure all fields are filled accurately before submitting.

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Versions	Form popularity	Fillable & printable
2019	4.4 Satisfied (26 Votes)

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