Primary Care Patient Forms

If you are a patient of South Shore Medical Center, you may be asked to fill out forms prior to your appointment.

Listed below, we have all of our Patient Forms in digital form so you can fill out them out at your convenience.

MyChart Forms

Below are PDFs of important South Shore MyChart forms. Please fax completed forms to 781-261-4432. Please note the Adolescent Access form must be signed onsite at South Shore Medical Center with the parent/guardian present.

Proxy access allows a parent, guardian, or other designated individual to connect to the South Shore MyChart account of a family member or friend. Access is granted once a signed paper authorization form has been completed and processed by the patient’s primary care site location.


Adolescent access allows an adolescent patient between the ages of 13 to 18 to view components of their medical record and communicate with their physician’s office regarding non-urgent matters. The parent/legal guardian will also be able to view a limited portion of the adolescent’s medical record. In order to obtain access, both the parent/legal guardian and the adolescent must complete and sign the Adolescent Access Authorization Form. If the adolescent has their own email address, they can provide it and will be given a code to access their own account. Adolescent Access is terminated when the patient or parent/legal guardian makes a written or online request to terminate access. At age 18, the patient will have full control of their South Shore MyChart account and the parent/legal guardian access will be discontinued. Beyond the age of 18 the patient may still grant parent/legal guardian access by completing a South Shore MyChart Adult Proxy Access Application (see above). This form requires a witness signature and must be signed onsite at South Shore Medical Center.


Pediatric and Disabled Teen proxy access allows you to securely communicate on behalf of a pediatric patient who is under the age of 13 (or 13 -17 years if the child is disabled). Access is obtained by completing the Pediatric and Disabled Teen Proxy Authorization Form. When the patient turns 13, this will transition to “Adolescent Proxy” access, with the ability to view a limited portion of the patient’s records.


South Shore Health offers a patient portal as a service to patients who wish to view their health information and communicate with their healthcare providers online. This patient portal is called South Shore MyChart, it is available to all South Shore Health patients.

Online access and secure messaging can be convenient and valuable communications tools, but they have certain risks. By agreeing to our Terms and Conditions, you agree to accept the risks and follow the procedures and Terms and Conditions.