FollowMyHealth™ Portal Sign-Up Patient Consent Form FollowMyHealth™ Portal Sign-Up The FollowMyHealth™ patient portal at Stamford Pediatrics is designed to enhance secure patient and provider communications and is provided as a courtesy to our valued patients. Please complete and submit this form to authorize Stamford Pediatrics to email an invitation to create a portal account.Age of the Patient:* Under 13 13-17 years old 18 or older Children Under Age 13Parent / Guardian Name:* First Last Parent / Guardian Email* Parent / Guardian Phone*Patient's Name* First Last Patient's Age*Children 13-17 Years OldWhen a patient turns 13 years old, the information available in the portal may be limited in accordance with state and federal law, and ethical considerations, relating to privacy rights of minors. For patients aged 13-17, portal access will be available, but only when both the parent/guardian and the minor patient agree to the access.Patient's Name* First Last Patient DOB* MM slash DD slash YYYY Patient Email (only required if patient wants portal access) Patient Phone (only required if patient wants portal access)Do you want to give permission to a Parent or Guardian to access information on your FollowMyHealth™ portal?* Yes, I would like to give permission. No, I do not want to give permission. I authorize Stamford Pediatrics to grant portal access to my parent/guardian.Patient Signature* Reset signature Signature locked. Reset to sign again Parent / Guardian Name:* First Last Parent / Guardian Email* Parent / Guardian Phone* I understand my child has agreed to grant me access to the Stamford Pediatrics portal. I have given my email for that purpose.Parent/Guardian Signature* Reset signature Signature locked. Reset to sign again Patients 18 or OlderOnce a patient turns 18 years old, portal access will need to be reset by the patient filling out a new form for portal access. An 18-year-old patient has the option to allow portal access to anyone they choose. Please fill out form below.Patient's Name* First Last Patient DOB* MM slash DD slash YYYY Patient Email* Patient Phone*Do you want to give permission to a Parent/Guardian or other individual to access information on your FollowMyHealth™ Portal?* Yes, I want to give permission to access. No, I do not want to give permission to access. I authorize Stamford Pediatrics to grant portal access to my parent/guardian or other.Parent/Guardian/Other Name First Last Parent/Guardian/Other Email* Parent/Guardian/Other Phone*Patient Signature* Reset signature Signature locked. Reset to sign again NameThis field is for validation purposes and should be left unchanged. Sign Up to Recieve Email Notificaitons Email address: Leave this field empty if you're human: Enter your email address below to receive practice announcements, medical updates, appointment reminders, and newsletters.