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Patient Portal Request Form

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Please fill in your information below. Once we receive your request we will send your username and temporary password. Once you log into your account you may change your password to one of your choosing.

Note: If a client is 18+ only the client can activate their portal account. For minors the portal account is assigned to whoever is listed as the Responsible Party on the account. Clients and Responsible Parties can consent for others to access a portal account by completing the Patient Portal Proxy Request Form.  Please contact kjvalerius@sundstromclinic.com for any questions

Portal account type:

Clients 18+ Years Old

Complete this section if you are a client 18+ years old

Patient Portal Proxy Request Form

Clients 18+ Years Old: If you would like to give consent to someone else to access your patient portal account, please check the box below. We will send you the Patient Portal Proxy Request Form via the email.

Responsible Party (Clients 0-17 Years Old)

Complete this section if you are the Responsible Party to a minor client.

Patient Portal Proxy Request Form

Clients 0-17 Years Old: Our system is not currently able to generate separate accounts for each parent/guardian. The account is associated with the child's account. Therefore parents/guardians should share the username and password for your child's patient portal account. If you would like to give consent to someone else who is not a parent/guardian to access your patient portal account, please check the box below. Please note that anyone you consent to give access will not be able to access all of the portal features. The Patient Portal Proxy Request Form will be sent to the email associated with the listed responsible party.

Thanks for submitting!

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