Name: | DOB: | MRN: | PCP:

MyDovetale Access For Patients Less Than 12 Years Old

**This form is to be completed by the parent/legal guardian (proxy)**

What is a Proxy?

  • A proxy is someone else who is authorized to have access to another person's MyDovetale account.

Who Can Assume Proxy Access?

  • An individual with adequate authority to act on behalf of a minor patient (under 12) ie. parent or legal guardian may request proxy access to the patient’s MyDovetale account.
  • The proxy may or may not be a patient of St. Joseph’s Healthcare Hamilton.
  • A proxy can be assigned varying levels of access to a patient’s MyDovetale account.
  • When a minor reaches 12 years of age, a proxy will no longer have access to the patient’s MyDovetale account. The minor will assume full responsibility of their account and may assign proxy access as they see fit.

If you are looking to request proxy access, please complete the form below.

All fields marked with an * are required.

Patient Information (Child)

Proxy Information (Parent/Legal Guardian)

Please select the type of proxy access you wish to be granted:*

Clinical Proxy
You will have full access to all information in the patient’s MyDovetale account, including the ability to schedule and message on behalf of the patient.

Scheduling and Messaging Proxy
You will have the ability to schedule and message on behalf of the patient, but will not have access to view any other information in the patient’s MyDovetale account.

Do you have a personal MyDovetale account?*
Have you ever been a patient at SJHH?*
My relationship to the minor patient is:*
Is there a court order in effect limiting your access to the minor’s medical records and information?*


By completing this form, I acknowledge and attest to the following:

  • All information provided during this process is true and current, to the best of my knowledge.
  • If provided proxy access, I understand that I am responsible for complying with the Terms and Conditions of MyDovetale, and that my access privileges may be revoked at any time.
  • Participating in MyDovetale is a voluntary decision made freely and without cohesion.
  • Should my legal authority to make health care decisions for the patient change in the future, I must contact SJHH immediately.
  • I am aware that all medical information contained in the patient’s MyDovetale account is obtained from their SJHH electronic medical record.

Applicable ONLY for Proxy Access to a Minor’s Account:

  • I attest that I am the parent or legal guardian of this patient.
  • I am aware that proxy access to my child’s MyDovetale account will be revoked on their 12th birthday.
  • I am aware that I may be contacted to verify my relationship with the patient prior to this account being activated.

For additional information about the request process or information about our privacy protection practices, please visit our website at