Proxy Parent/Legal Guardian Information: First Name Last Four Digits of SSN Street Address State Home Phone Number Last Name Date of Birth City Zip Code E-mail Address Gender MaleFemale Relationship to Patient ParentLegal Guardian Patient Information: First Name Last Four Digits of SSN Insurance Provider Primary Care Physician Address (if different from parent/guardian) Last Name Date of Birth Patient 2 Information: (Optional) First Name Last Four Digits of SSN Insurance Provider Primary Care Physician Address (if different from parent/guardian) Last Name Date of Birth Patient 3 Information: (Optional) First Name Last Four Digits of SSN Insurance Provider Primary Care Physician Address (if different from parent/guardian) Last Name Date of Birth I hereby request access to my child or children's electronic health record. * I certify that I am the parent or legal guardian of the child or children listed here.
