Register for Our Online Patient Portal

Patient Name*
Patient's Date of Birth*
Parent/Guardian Name (if applicable)
By signing and dating this form, I am authorizing Montrose Regional Health 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*
Today's Date*

Confirm Registration Form Sign-Up

Whenever a new item is posted to your patient portal, such as results, reports, appointments etc., 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 the Patient Portal page on our website to access your portal or to learn more about the patient portal. You will submit this form by clicking on the "submit" button below.
This field is for validation purposes and should be left unchanged.

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