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. The code is active for 24 hours. After that, you need to request a new link.
If you have not received a code within 3 business days, please call health information management at 937-641-3395.
If you have more than one child, you will still only receive one link to create your account. You can view your additional children 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: Your request may be delayed if any of the above information is missing in your form, or if we are unable to verify the requesters’ identity based on the information provided. We may also request birth certificate and/or guardianship paperwork to verify your identity.
Requestor Information:
To complete this section:
• 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.