MyChart -

Now you can take control of your health care the easy way with MyChart! If you are a patient of Texas Childrens and over the age of 18, you are eligible to sign up for a MyChart account today! Complete the form below in its entirety, and submit the request. We will e-mail your access code and registration instructions to you within 24 hours of receipt of this form, with the exception of weekends and holidays.

Location Visited:

First Name:

Last Name:

DOB(xx/xx/xxxx):

SSN(Last four digits):

Address:

City:

State:

Zip Code:

Phone Number(xxx-xxx-xxxx):

Email Address:

Your Physician:

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MyChart Access Request