Seattle Children's MyChart -

Thank you for your interest in Seattle Children's MyChart, a free application where you can access your medical record. Learn More

This form is for a patient, 13+ years old, to request their own MyChart account. Features available are limited for patients that are 13-17 years old.

We will contact you if we have questions. Please note to check your email account’s spam folder.

Items marked with an * are required for this section.

*Your First Name:

Your Middle Initial:

*Your Last Name:

*Your Date of Birth (mm/dd/yyyy):

*Address:

*City:

*State:

*Zip Code:

*Phone (xxx-xxx-xxxx):

*Email Address:

Comments:

PLEASE READ AND CERTIFY

By clicking below, I acknowledge that I have read, understand and agree to Seattle Children's MyChar terms and conditions. By signing as a patient, I represent that I am over 13 years of age and would like my own access to MyChart.

I Certify:

Yes

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Request MyChart Access to Your Record

PLEASE READ AND CERTIFY