Patient Portal Request - East Suburban Pediatrics

Request for My Kid's Chart Patient Portal Access

Complete the information below to register for East Suburban Pediatrric's online patient portal. Once your account is created, you will receive an email with a temporary password that is active for 1 week. You need to sign into the portal to complete your account set-up. Please verify that your name appears correctly and that the names of the patients you have requested access to appear on the screen.

This field is for validation purposes and should be left unchanged.

Parent/Guardian Name(Required)

First Last

Email Address(Required)

This will be your user name.

Child #1 Name(Required)

First Last

Date of Birth (Child #1)(Required)

Child #2 Name

First Last

Date of Birth (Child #2)

Digital Signature(Required)

Type your name acknowledging....