Patient Portal Enrollment request Form

Established Patients - If you have not already received an email from in the last 48 hours, please use this form to request enrollment in the Patient Portal.

  • Once we receive your completed form and after validating your information, we will send you an email from ( with instructions on how to complete your enrollment. Please click the link in the email as soon as you receive it, as it will expire in 30 days.
  • Enrollment invitations are only sent to people 12 years of age or older.
  • If your child is under 12 years of age, you can use this form to enroll them in the portal. If you are a parent/guardian of this child AND a Core patient, it is best to enroll yourself BEFORE requesting access to enroll your child. Please see our patient portal FAQ page for more information.
  • Please allow up to 7 business days to receive your email enrollment invitation. If you need to reach your provider’s office sooner, please call them directly.

New Patients - Please reach out directly to your provider’s office to register in our system. At that time you will receive a patient portal enrollment email invitation.

Already Enrolled Patients - If you are already enrolled in the Core Physicians' Patient Portal, please do not complete this form. Instead, request assistance  by completing our patient portal assistance form.

Adult or Adolescent Patient (12+)

To request the addition of a dependent (child under 12) to your patient portal account

You must be the parent or legal guardian of the child/children listed below. Once a child turns 12, access will expire. If you are also a Core patient, it is best to enroll yourself first BEFORE requesting access to enroll your child.