Sage Hill School myChart Form

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)

Name

First*

Last*

Date of Birth (MM/DD/YYYY)*

Phone Number*

Address

Address*

Address 2

City/Town*

State/Province*

ZIP/Postal Code*

Email*

Do you have an active myChart account with MemorialCare?

Yes

I don't know

Insurance Information Required

Insurance Name*

Member ID*

Add a Dependent?

I would like to include my dependent at Sage Hill School for the Virtual Clinic

Communication Confirmation

Allow MemorialCare and TytoCare to send me future communications on how to receive care with the Virtual Clinic.

Dependent's Name

First

Last

Dependent's Date of Birth (MM/DD/YYYY)

Signature*

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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