MyChart -

Thank you for your interest in MyChart at Akron Children's Hospital. You are just a few steps away from secure, 24/7 access to your health information.

To sign up for access, please complete and submit the following form for approval. Once your request has been received, we will send a secure, activation email within 7 business days. We will contact you by phone or email if we have any questions.

Note: * indictates required field on the form.

Adult Patient Information

First Name:

Middle Name:

Last Name:

Date of Birth (xx/xx/xxxx):

Address:

City:

State:

Zip Code:

Phone (xxx-xxx-xxxx):

Email Address:

Drivers License or State ID Number:

Requesting Access for:

New Akron Children's MyChart Account

PLEASE READ AND CERTIFY

I am an adult patient who is 18 or older of Akron Children's Hospital. All information I have provided is correct. By signing this form, I acknowledge that I am requesting access to my own MyChart account according to Akron Children's Hospital terms and conditions.

Click the statement to the right to sign this form electronically (It will turn blue when clicked):

Yes, I certify that I am the patient and I am requesting access to my own MyChart account.

Back to the Login page

Akron Children's Adult Patient MyChart Enrollment Form

Adult Patient Information

PLEASE READ AND CERTIFY