Montrose Memorial Hospital Patient Portal Registration Form

The Montrose Memorial Patient Portal provides secure online access to portions of your MMH Medical Record. Simply complete the information and submit to our secure patient portal.

(*) denotes required information.

* Patient Name:
* Patient's Date of Birth:
* Phone Number:
* Email:
* Last 4 Digits of SSN:
Address:
Parent/Guardian:
 
By Signing and dating this form, I am authorizing Montrose Memorial Hospital to create a patient portal Logon ID and password for the patient listed above. I understand that this information will be emailed to me within 3 business days at the email I have given above.
 
* Patient E-Signature:
* Date:
 

Once the registration form is completed and returned to Medical Records, you will receive an email with a link to the patient portal. (Within 3 business days) This will include your one time logon ID and one time password information. Please make sure you check your bulk, junk or spam email, because it may have filtered there. Once you receive your one time logon ID and one time password, please follow the prompts. Copy and paste your one time user ID and password into the fields. You will then be prompted to create a new user name and password. You will need to read and accept the Terms and Conditions of the patient portal before it can be accessed.

Whenever a new item is posted to your patient portal, such as results, reports, appointments ect, you will receive an email notification. There will be a link at the bottom of the email directing you to the portal log in screen. No health information is relayed in any email. All email addresses will be kept confidential and will not be used for marketing or solicitation.

You may go to http://montrosehospital.com/medical-services/patient-portal to access your portal or learn more about the patient portal.

You will submit this form by clicking on the "submit" button below.