Request Access to Patient Portal - Lake Regional

Lake Regional Health System patients (or their parents/guardians) can request online access to their health information by filling out the form below.

Note: If you are having trouble creating your account or logging in, access the Support Portal for self-help and chat support. Support is also available anytime by phone at 888-443-8271.

Patient First Name

Patient Middle Initial

Patient Last Name

Patient Date of Birth

Patient Daytime Phone Number

Patient Gender

Patient Email Address

Patient Zip Code

Are you requesting access to someone else's records? (i.e. child)

Yes

Parent/Guardian Relationship

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Date of Birth

Conditions & Treatments

Doctors

Locations

Pages