St. Jude MyChart -

We need some information from you in order to set up a St. Jude MyChart account for you to access your child’s medical information. Please fill out the below form. If we are able to match you in our system you will be able to create your account today. If not, you will be shown a message with instructions for completing your signup with the help of our MyChart Patient Help Desk.
Proof of parental rights, legal custody, guardianship, power of attorney or similar, or other rights to access the patient’s medical information must be on file before a St. Jude MyChart account can be set up.

Patients 14 and above requesting access click here

Consenter Information

Please fill this out with the information of the person requesting access.

Consenter First Name*

Consenter Middle Name

Consenter Last Name*

Consenter Date of Birth*

Last 4 of Consenter SSN

Consenter E-Mail Address*

Consenter Preferred Phone*

Street Address*

City*

State*

Zip Code*

Relationship to Patient*

ParentLegal GuardianOther

Patient Information

Please fill this out with the information about the patient you are a consenter for.

Patient First Name*

Patient Middle Name

Patient Last Name*

Patient Date of Birth*

Patient Medical Record Number

Please Read and Certify

By clicking “Yes” below, I certify that I am the parent or legal guardian of the child (or have legal authority to access the patient’s medical records) and that all information I have provided is correct. By signing this form, I acknowledge that I have read and understand this St. Jude MyChart Access Request Form and I agree to St. Jude MyChart’s Terms of Use and the Proxy Disclaimer . I hereby request access to my child's medical record through St. Jude MyChart. I understand that proof of parental rights, legal custody, guardianship, power of attorney or similar, or other rights to access the patient’s medical information must be on file before a St. Jude MyChart account can be set up.

I certify*

Yes

If you have any questions, please contact us.

Access Your Child's Chart