Sentara MyChart Patient Forms

Forms You May Need

MyChart Permission Slip - Teens (Ages 14-17)

As a parent/legal guardian, you can request that your teen ages 14-17 have access to their online medical record using this form.

MyChart Proxy Access Authorization Form - Teens (Ages 14-17)

A proxy is a person who can view patient information as if they were you. Use this form for teens ages 14-17 to gain proxy access to your teen's MyChart account. Please Note: Requires that the teen child have their own MyChart account activated to view.

MyChart Proxy Access Form - Adults and Children

A proxy is a person who can view patient information as if they were you. Use this form to grant a spouse, adult child or caregiver access to your medical records. You may also use this form to gain access to your child’s record if they are under the age of 14.