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Sunday, May 19th, 2019

Portal Enrollment Form

Clinical Pediatric Associates
8355 Walnut Hill Lane Suite 105
Dallas, TX 75231
Phone: 214-368-3659
Fax: 214-739-8923

Online Patient Portal Enrollment Form

When you access our patient portal, you can review a complete health
information summary for each child in your care, including:

  • Most recent physical date
  • Upcoming appointments
  • Historical visits
  • A summary of labs and medical tests
  • A problem list, allergy list and medications list
  • A complete immunization record that may be downloaded or printed

You will also be able to communicate with our office by sending and receiving
secure messages via our portal.
To sign up for access, complete the fields below and return the form to us via
the submit button to complete enrollment. You will then receive an email from us with
your login and temporary password.

If your child is over the age of 18, then they must submit their own information. Unless we have a signed release, parents cannot access their child's records if they are over 18.

Parent Name:
Signature(Please type your full name):
Phone Number:
Email Address:
Children's names that you wish to have access to:

If you would like to view balances and utilize our online bill-pay functionality, please sign below in order to have access to BluePay

Signature(Please type your full name):
Verification Image:
Try Another Image
Image Text:
Type the text in the "Verification Image".

After Hours:
214-368-3659 (Option 7)
8355 Walnut Hill Lane, Suites 105 & 205 Dallas, TX 75231
© Clinical Pediatric Associates. All rights reserved.
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