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Home > Medical Center > Forms > Clinical Care Forms and Consents > Clinical Forms > University Health > PARENT/LEGAL GUARDIAN/ANOTHER ADULT PROXY ACCESS TO ADOLESCENT MYCHART (CHILD AGED 13-17 YEARS OLD)

form 211101 : PARENT/LEGAL GUARDIAN/ANOTHER ADULT PROXY ACCESS TO ADOLESCENT MYCHART (CHILD AGED 13-17 YEARS OLD)

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view  |  PDF document icon 211101 Parent_Legal Guardian_Other Adult Proxy Access to Adolescent MyChart (Nov_2021).pdf — PDF document, 126 KB (130032 bytes)


  1. effective date:

    February 2022

version information:

document number:   211101
document owner:   Scottie Frey
effective date:   February 2022
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  1. Search for and choose the appropriate document. 
  2. Right click the document PDF
  3. Select “Copy shortcut”
  4. Send an email with the PDF form attached to hospcopy@virginia.edu and include the following information:
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