Patient Portal OPT-OUT Form

Patient Portal OPT-OUT Form
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Phone Number Type*

Cell PhoneHome PhoneWork Phone
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.*

By checking this box, I acknowledge that I have read and hereby agree with the terms and conditions above.
Signature*

Clear
Signer's Name*

First NameLast Name
Should be Empty: