Name: | DOB: | MRN: | PCP:

Activation Code Request & Consent

Thank you for your interest in Seattle Children's MyChart - Schedule and Pay, a free web site where you can schedule appointments and pay your bills. Learn More

Who can sign up for MyChart - Schedule and Pay?

  • Adults who pay the bill for a patient at Seattle Children’s
  • Adults in our records who can bring patients to appointments at Seattle Children’s
  • Patients 13 and older who have been to Seattle Children’s for treatment

To sign up, please complete and submit the form below. If you have more than three children for who recieve care at Seattle Children's, please complete another form.

Please expect the application process to take 7 days. Once we have reviewed your information, we will contact you if we have any questions.

User Information

Items marked with an * are required for this section.

I want to:

I am the legal guardian and I request/give permission for the following person to have access to MyChart.

Patient Information

Items marked with an * are required if you fill out this section.

*Relationship to Patient:

Patient Information

Items marked with an * are required if you fill out this section.

*Relationship to Patient:

Patient Information

Items marked with an * are required if you fill out this section.

*Relationship to Patient:

PLEASE READ AND CERTIFY

Information I have provided above is correct and complete. I acknowledge that I have read and understand this Seattle Children's MyChart - Schedule and Pay Consent Form and I agree to its terms and conditions.

I Certify: