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The MemorialCare Virtual Health Team will need the following information to create a record for you in their healthcare system which will also provide you access to their patient portal, myChart. MyChart allows you to schedule appointments directly from the app or the website which will be needed to schedule your appointment with the Virtual Clinic. Please see the MemorialCare Virtual Clinic flyer for more information about accepted insurances.

Your Information (all fields required)

Do you have an active myChart account with MemorialCare?

Insurance Information Required

Add a Dependent?
Communication Confirmation
Dependent's Name
I understand that with my signature below, I am granting MemorialCare and Sage Hill School to use the information provided, to create a myChart account on my behalf.
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