Patient Portal Registration

Registration Form

By submitting this form, you are authorizing Piedmont Pediatrics to utilize information obtained from this form to initiate your 'My Kid's Chart' patient portal. Once your patient portal is successfully initiated on our end, you will receive instructions and your temporary password for portal access. Patient portal initiation is a manual process, so please at least 24-48 hours from form submission to receive your portal activation confirmation. Any errors on this form could delay portal access.

Portal User's First and Last Name(Required)

First Last

If another parent would like a separate login, please submit another form with that user's information.

What is your relationship to the below patients?(Required)

Self, Mother, Father, Aunt, Guardian, etc

Which would you like to use as your username for your portal?(Required)

Please make a selection from the dropdown box.

Please input your phone number here:(Required)

xxx-xxx-xxxx

Please input your email here:(Required)

example@piedmontpediatrics.org

Please list names and dates of birth for ALL patients whom should be associated with this portal user.(Required)

The patients listed here will be the patients' whose charts appear to the above portal user. Patients over eighteen(18) must grant additional access to other portal users other than themselves by submitting a 'Parental Authorization Consent Form' found on our website.