Name: | DOB: | MRN: | PCP:

Request MyChart Access to Your Record

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.

Please expect the application process to take up to 7 days. 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.

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: