Patient Portal OPT-OUT Form

Patient Portal OPT-OUT Form
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number Type
Current E-mail Address

Confirmation Emailexample@example.com
Registered E-mail Address for Portal Account

Confirmation EmailPlease enter the e-mail address that you used for the portal account
By opting out of the patient portal (myEMGchart), you will no longer have accessibility to any of the portal features:
- Sending or receiving messages from your doctor or support staff
- Viewing laboratory results
- Requesting appointments
- Viewing upcoming appointments
- Viewing referrals
By completing and signing this form you acknowledge your patient portal access will be disabled.
Signature
Signer's Name

First NameLast Name
Should be Empty: