Teen Connection

Teen Connection

Minor children between 14 – 17 years of age may establish their own My Chart account, via MyUnityPoint, if they obtain parental or legal guardian authorization. The parent or guardian must complete and sign this form for access to be granted.

Required fields indicated by *

Patient Information

Patient's Date of Birth *
/ /

Parent/Guardian Information

Parent/Guardian Date of Birth *
/ /
Identify your relationship to the Proxy *