MyChart -

MyChart offers secure online access to your health record for care you received at any one of these hospitals located in the Central East. Campbellford Memorial Hospital, Haliburton Highlands Health Services, Lakeridge Health, Northumberland Hills Hospital, Peterborough Regional Health Centre, Ross Memorial Hospital, and Scarborough Health Network.

Minor Information

Fields marked with an asterisk (*) are required.

First Name*

Middle Name

Last Name*

Which hospital did you last visit*?

Date of Birth (dd/mm/yyyy)*

Patient Ontario Health Card Number or Medical Record Number (MRN)*

Address Line 1*

Address Line 2

City*

Province*

Postal Code*

Proxy Information (e.g. Parent, Legal Guardian)

Relationship to Patient*

ParentLegal GuardianOther

Relationship to Patient (if selected other)

First Name*

Middle Name

Last Name*

Date of Birth (dd/mm/yyy)*

Email Address*

Phone Number*

Signature

By clicking "Submit" you are agreeing to the terms and conditions and applicable proxy designation statements. You may deactivate MyChart access at any time by contacting the Regional MyChart support line at 1-833-789-3742.

Proxy Consent (Type Full Name)*

Disclaimer

Your proxy access request will be reviewed by a member of your healthcare facility. You may be contacted by a member of that healthcare facility at the number provided on your application prior to proxy access being granted. You may also be required to provide proof of authorization for access (i.e. custodial agreements, power of attorney for care, etc.).

Central East Hospital Cluster Minor Proxy Access Request