Patient Portal Access

Please fill out the following form to request Patient Portal access for your child(ren).

**Attention** This form is to request portal access to Pediatric Associates, PC in Richmond, Virginia.

Portal Access

Step 1 of 2

Your Name*
First Last
Children's Information
Please fill in the information for each child.
Number of Children on this Account*
- 1
- 2
- 3
- 4
Child 1

Please list the following information for the first child:
Legal Name*
First Middle Last
Birthdate*
Child 2

Please list the following information for the second child:
Legal Name*
First Middle Last
Birthdate*
Child 3

Please list the following information for the third child:
Legal Name*
First Middle Last
Birthdate*
Child 4

Please list the following information for the fourth child:
Legal Name*
First Middle Last
Birthdate*
Address where Children Reside*
Street Address Address Line 2 City State ZIP Code

Authorized User Information
Person receiving access to Patient Portal Account
Name*
First Last
Relationship to child(ren)*
Birthdate*
Same address as child(ren)?*
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
Email Address*
This is the email that will receive Patient Portal Messages
Enter Email Confirm Email
Home Phone*
Cell Phone
if different from home phone
Comments
This field is for validation purposes and should be left unchanged.

Additional Forms

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Other Patient Forms

Appointments Available Every Weekday & Saturday

We are open every weekday from 8:00am to 5:00pm and have sick appointments available daily. On Saturdays, our Waterford office is open starting at 8am for sick visits (by appointment only).

Patient Portal Access

Portal Access

Step 1 of 2

Children's Information

Child 1

Child 2

Child 3

Child 4

Authorized User Information

Additional Forms

Other Patient Forms

Appointments Available Every Weekday & Saturday