Online Enrollment Form

Thank you for your interest in Dayton Children's MyKidsChart, an easy-to-use tool that provides you quick and secure online access to some of your child's health information.

MyKidsChart Online Enrollment Process

To sign up for access to your child's Dayton Children’s MyKidsChart record, please complete and submit the following form for approval. Once your request has been received, we will send you a link with an activation code within 3 business days.

However, if any of the enrollment requirements (listed below) are missing in your submission or if we are unable to verify the requesters’ identity based on the information provided, your request could be delayed.

If you have not received a code in the alloted time, please call Health Information Management at 937-641-4535. Note that the activation link is valid for 24 hours, and if not used by that time, a new link is required.

If you have more than one child, you will still only receive one link to create your account. Your additional children will be viewable once you begin.

Online Enrollment Requirements

To approve your request, we require the following:

1. Type of access:

  a. For Parent/Legal Guardian access: Your child (the patient) is less than 18 years

   • If your child is 18 years or older, you cannot request or will no longer have access to your child's Dayton

      Children’s MyKidsChart record (unless guardianship paperwork is provided)

  b. For Patient access: You are 18 years or older

   • For patients 14 to 17 years old, you are able to request your own account, but the request must be

      completed in person during a hospital or clinic visit.

2. Driver's license

3. Insurance ID/group number is required

Please Note: If any of the above information missing is in your request submission or if we are unable to verify the requesters’ identity based on the information provided, your request could be delayed. We may also request birth certificate and/or guardianship paperwork to verify your identity

Requestor Information:

To complete the form:

 • Please enter your information, not your child’s (the patient), if your child is under age of 18 years old.

 • For patients (not parents) over 18 years old, please enter your information (including your personal email

   and cell).

 • If your child is 18 years or older, you cannot request access to your child's Dayton Children’s

   MyKidsChart record (unless you are their guardian and guardianship paperwork is provided).

Asterisks (*) indicate required fields.

Click here to securely upload your photo ID

I clicked the above link and submitted a copy of my Driver’s License Number or State ID. I understand if not uploaded, it will result in a delay in processing my request

Account Type:

Click Existing Account if you currently have access to another patients account within MyKidsChart.

Click New Account if you currently have no access to MyKidsChart. 



Requesting Access for:

Patient Information:

Relationship to patient:
*Legal Guardianship papers must be on file before full access can be granted.

Additional Patient Information:

Relationship to patient:
*Legal Guardianship papers must be on file before full access can be granted.

Additional Patient Information:

Relationship to patient:
*Legal Guardianship papers must be on file before full access can be granted.

How would you prefer your activation code be delivered?

Once your request has been received and approved, we will send you an activation link within 3 business days.
Delivery Methods:
You must have the Email or Cell Phone number populated above in order to send to the preferred method.

PLEASE READ AND CERTIFY

I am the patient, or have a relationship as stated, with the patient and/or patients listed above and that all information I have provided is correct. By signing this form, I acknowledge that I have read and understand this Dayton Children's MyKidsChart Consent Form and I agree to its terms and conditions. I hereby request access to my or the patient and/or patient's online health record.

I Certify
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