FMH Access Request Form

Consent*
I give permission for Center City Pediatrics to provide me a login to access my child (ren)’s online health record.
Your Name*
First Last
Email*
Phone*
Select a 4-digit PIN of your choice to serve as your FMH Invitation Code*
Name of child*
Date of birth*
MM slash DD slash YYYY
Do you have any additional children to enroll in FMH today?*
- Yes
- No
Name of child*
Date of birth*
MM slash DD slash YYYY
Do you have another child?*
- Yes
- No
Name of child*
Date of birth*
MM slash DD slash YYYY
Do you have another child?*
- Yes
- No
Name of child*
Date of birth*
MM slash DD slash YYYY
Relationship*
- Mother
- Father
- Step Mother
- Step Father
- Guardian
- Other
Other*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Please note that this information above will invite a proxy to join our patients’ online health records. This information will NOT be updated or entered into your child (ren)’s account.
Acknowledgement*
Upon submission of this form, you will receive an email verifying your information and prompting you for your 4-digit invitation code. This account will not be activated until the steps outlined in that email are complete.
Signature*

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Primary Sidebar

*Non-medical inquiries only

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33 Rock Hill Rd
Suite 170
Bala Cynwyd, PA 19004
Call: (610) 257-9000
Fax: (484) 270-8133

1740 South Street
Suite 200
Philadelphia, PA 19146
Call: (215) 735-5600
Fax: (215) 735-5690

2365 East York Street
Philadelphia, Pennsylvania 19125
Call: (215) 278-2500
Fax: (215) 644-9083