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Form analysis
1 forms found in the DOM

POST /MyChart/accesscheck.asp

<form autocomplete="off" method="post" action="/MyChart/accesscheck.asp" id="signupForm" onsubmit="return checkUserId('/MyChart/en-US/Images/warning.png');">
  <div class="formcontents">
    <div class="hidden"><input type="hidden" class="hidden" name="sec_token" value="C098EB6D7CEB4681951CB50F62E635C6" autocomplete="off"></div>
    <div class="hidden"><input type="hidden" class="hidden" name="instactsignuptoken" value="D5C0FD81B1BB49D18D8D2A2851113E7E" autocomplete="off"></div>
    <div id="locale_container" class="prelogin">
      <a href="/MyChart/accesscheck.asp?InstAct=WP-24pTw1hS24PFviIjTd7ZQ4Xv6mZlAJNYefzV83ZUsveVQ-3D-24M9i5xE1ctMp6dyt9dp6NTg40SdAJO3kCCV06V-2FsyoAI-3D&amp;lang=espanol" onclick="$$WP.Utilities.TryRedirect(this.href); return false;"><span class="localename">Ver en Español</span><abbr class="abbreviatedname" title="Ver en Español">Esp</abbr></a>
    </div>
    <div class="title">
      <h1 class="header">MyChart Signup: To register for your own MyChart account, you may use the same email address as other family members, but the email address cannot be used as your username. A unique user name and password must be created for
        each individual.</h1>
      <div id="assistiveicons"><img class="assistiveicon" alt="" src="/MyChart/en-US/images/space.gif"></div>
    </div><input type="hidden" class="hidden" name="instactcode" value="8oJnWeu0X8hPL3XOplLIlgXX" autocomplete="off"><input type="hidden" class="hidden" name="instactqueryparam"
      value="WP-24pTw1hS24PFviIjTd7ZQ4Xv6mZlAJNYefzV83ZUsveVQ-3D-24M9i5xE1ctMp6dyt9dp6NTg40SdAJO3kCCV06V-2FsyoAI-3D" autocomplete="off">
    <div id="loginDiv">
      <div id="signuperror" class="alert signUpFieldError"></div>
      <div class="formsection">
        <label for="login">MyChart username</label><input class="jsreq" type="text" id="login" name="Login" value="boydprtt1@gmail.com" maxlength="128" onkeyup="" onblur="" autocorrect="off" autocomplete="off">
      </div>
    </div>
    <div id="Loginerror" class="alert signUpFieldError"></div>
    <div id="passwordDiv">
      <div id="passwordFieldDiv" class="formsection">
        <label for="Password" id="PasswordLabel"> <span class="label">Create password</span>
        </label><a href="#" id="pwdButton"><img id="pwdButtonImg" src="/MyChart/en-US/images/info_grey.png" alt="Screen readers: use read next line command to hear password guidelines." title="" onclick="showGuideLines();"></a><input type="password"
          name="Password" id="Password" onkeyup="isPasswordFieldsError(this,document.getElementById('Retype'),'',1,'',1); matchPasswordFields('Password','PasswordText','showPwd'); updPwdStrClient();"
          onblur="isPasswordFieldsError(this,document.getElementById('Retype'),'','',1,1); matchPasswordFields('Password','PasswordText','showPwd'); updPwdStrClient(); togglePwdStrengthDiv();" onfocus="togglePwdStrengthDiv();" width="90%"
          autocomplete="off"><input class="hidden" type="input" name="PasswordText" id="PasswordText"
          onkeyup="isPasswordFieldsError(this,document.getElementById('Retype'),'',1,'',1); matchPasswordFields('Password','PasswordText','showPwd'); updPwdStrClient();"
          onblur="isPasswordFieldsError(this,document.getElementById('Retype'),'','',1,1); matchPasswordFields('Password','PasswordText','showPwd'); updPwdStrClient(); togglePwdStrengthDiv();" onfocus="togglePwdStrengthDiv();" width="90%"
          autocomplete="off">
        <div id="pwdGuidelines">
          <div id="pwdInstructions" class="hidden">Must contain at least: <ul>
              <li>One lowercase letter.</li>
              <li>One uppercase letter.</li>
              <li>One number.</li>
              <li>One special character.</li>
            </ul>
          </div>
        </div><button type="button" id="showPwd" name="showPwd" onclick="showPassword('Password','PasswordText','showPwd','PasswordLabel')" autocomplete="off">Show</button>
      </div>
      <div id="LoginPassworderror" class="alert signUpFieldError">
      </div>
    </div>
    <div id="passwordStrength" class="hidden">
      <div id="pwdStrLabel">Password strength<br style="display: none;"></div>
      <div id="pwdStrengthDiv0"></div>
      <div id="pwdStrengthDiv50"></div>
      <div id="pwdStrengthDiv75"></div>
      <div id="pwdStrengthDiv100"></div>
      <div id="passwordStrengthWords"></div>
    </div>
    <div id="verificationItemsDiv">
      <script type="text/javascript">
        var sEmptyFieldErrorDOB = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Please enter your date of birth."),
          sInvalidFieldErrorDOB = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Invalid date of birth.");
      </script>
      <fieldset class="formsection">
        <legend class="compact header small">Date of birth</legend><label class="clearlabel inlinelabel" for="dob1">Month of birth</label>
        <div class="segment2"><input class="jsreq" type="number" name="dob" id="dob1" maxlength="2" value=""
            onkeyup="autotab(event,this,document.getElementById('dob2')); isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'1',this,'1','1');"
            onkeydown="easyDOBEntry(this,1,'',1); checkIfTabAllowed(event,this); checkIfFocusOnPrevField(event,this,'dob',1);"
            onblur="easyDOBEntry(this,1); isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'',this,'1','1');" onclick="selectIfFull(this);" onkeypress="removeCharFromField(event,this,'/','2');"
            autocomplete="off">
          <div class="helptext accessibleLabel" aria-hidden="true">mm</div>
        </div><span class="separator subtle" aria-hidden="true">/</span><label class="clearlabel inlinelabel" for="dob2">Day of birth</label>
        <div class="segment2"><input class="jsreq" type="number" name="dob" id="dob2" maxlength="2" value=""
            onkeyup="autotab(event,this,document.getElementById('dob3')); isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'1',this,'1','1');"
            onkeydown="easyDOBEntry(this,1,'',1); checkIfTabAllowed(event,this); checkIfFocusOnPrevField(event,this,'dob',2);"
            onblur="easyDOBEntry(this,1); isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'',this,'1','1');" onclick="selectIfFull(this);" onkeypress="removeCharFromField(event,this,'/','2');"
            autocomplete="off">
          <div class="helptext accessibleLabel" aria-hidden="true">dd</div>
        </div><span class="separator subtle" aria-hidden="true">/</span><label class="clearlabel inlinelabel" for="dob3">Year of birth</label>
        <div class="segment4"><input class="jsreq" type="number" name="dob" id="dob3" maxlength="4" value="" onkeyup="isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'1',this,'1','1');"
            onkeydown="easyDOBEntry(this,1,1,1); checkIfTabAllowed(event,this); checkIfFocusOnPrevField(event,this,'dob',3);"
            onblur="easyDOBEntry(this,1,1); isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'',this,'1','1');" onclick="selectIfFull(this);" onkeypress="removeCharFromField(event,this,'/','2');"
            autocomplete="off">
          <div class="helptext accessibleLabel" aria-hidden="true">yyyy</div>
        </div>
        <div id="doberror" class="signUpFieldError"></div>
      </fieldset>
    </div>
    <div id="secResponsesDiv"></div> <input class="button jsreq completeworkflow" type="submit" name="instactsignup" id="instactsignup" value="Submit" title="" autocomplete="off">
  </div>
</form>

Text Content

Ver en EspañolEsp


MYCHART SIGNUP: TO REGISTER FOR YOUR OWN MYCHART ACCOUNT, YOU MAY USE THE SAME
EMAIL ADDRESS AS OTHER FAMILY MEMBERS, BUT THE EMAIL ADDRESS CANNOT BE USED AS
YOUR USERNAME. A UNIQUE USER NAME AND PASSWORD MUST BE CREATED FOR EACH
INDIVIDUAL.


MyChart username

Create password
Must contain at least:
 * One lowercase letter.
 * One uppercase letter.
 * One number.
 * One special character.

Show

Password strength






Date of birthMonth of birth
mm
/Day of birth
dd
/Year of birth
yyyy