Name: | DOB: | MRN: | PCP:

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. 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 an activation link within 3 business days.

If you have not received a code in that time, please call Health Information Management at 937-641-4535. Note that this 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.

Please note there could be a delay with processing your request due to, but not limited to the following reasons:

1. If your child is 18 years or older, you will no longer have access to your child's Dayton Children’s MyKidsChart record.

2. If we are unable to verify the requesters identity based on the information provided below.

3. Driver's license and insurance ID/group number is required.

Click here to securely upload your photo ID.

4. Driver's license, birth certificate or guardianship paperwork may be requested to verify your identity.

Requestor Information:

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?

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