MyChart -

MyChart is a secure portal that connects patients and families with your provider via the MyChart App or the online portal. It offers useful information such as upcoming appointments, most lab and imaging test results, different types of visit summaries and much more!

Proxy access automatically expires when the patient reaches the age of 12 and 16 and requires a new application to reactivate.

Apply for access now by submitting this form.

All fields marked with a * are required.

Patient Information

First Name*

Middle Name

Last Name*

Patient Ontario Health Card Number or Medical Record Number (MRN)*

I don't know my MRN, what should I do?

Address Line 1*

Address Line 2

City*

Province*

Postal Code*

Date of Birth (dd/mm/yyyy)*

Proxy Information (e.g. Parent, Legal Guardian)

Relationship to Patient*

FatherMotherLegal GuardianOther

Relationship to Patient (if selected other)

Proxy First Name*

Proxy Middle Name

Proxy Last Name*

Proxy Date of Birth (dd/mm/yyyy)*

Proxy Email Address*

Proxy Phone Number* (no spaces or dashes)

Signature

By clicking "Submit", I agree to the use, disclosure and sharing of personal and personal health information through the MyChart portal and I understand and agree to Terms and Conditions related to MyChart and the release of information and proxy designation (if applicable) which is available here. A copy of these Terms and Conditions will also be provided to you upon request.

Proxy Consent (Type Full Name)*

CHEO Parent/Legal Guardian (Proxy) Access - Under 12