Patient Portal Access Request

Request Access To Patient Portal
To request access to your online patient portal, please fill out the form below. We will review it within 3 business days and send your portal access code and instructions to your address. If you need access to your patient portal more urgently, please contact our office.

Per NYS and HIPAA requirements, if your child is 12 years old or older, we must have a signed Portal Release Form from your child allowing the parent/guardian to have access to the child’s portal account. Access will be granted only to the parent/guardian who has been authorized in writing and listed on the Portal Release Form. The Portal Release Form must be signed in the presence of and witnessed by a member of the office staff.
Patient's Name*

First NameLast Name
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's DOB*

MonthDayYear
Date
Patient’s Email*
example@example.com
Patient's Phone Number*

Area CodePhone Number
Please complete the information below if you are a parent or guardian requesting access to the patient’s portal account.
Your Name

First NameLast Name
Your DOB

MonthDayYear
Date
Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Email
example@example.com
Your Number

Area CodePhone Number
Relation to Patient
Should be Empty:

Request Access To Patient Portal