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.

Sentara in the Community