Coastal Family Practice

and Acute Care Center, LLC.

This form requires Adobe Reader to view and print. Click here to download.

Please print and and complete these forms. You can scan and email them to info@coastalfamilypractice.net or use the file upload link on this page. You can also fax them to 850-231-9287.

You can also register online. Please click the Secure Online Registration tab above if you wish to use this method to register.

New Patient Online Registration

Please use one of the 2 registration methods listed below. We recommend Secure Online Registration but you can also print the New Patient Registration Form and follow the instructons below.

A member of our staff will reach out to you to schedule your first appointment once your registration is received if one has not already been made.

File Upload

Please click choose file to upload new patient registration forms (paper/hardcopy), identification card, insurance card(s), medication lists, medical records release forms etc. (only 1 at a time. Reload page if you need to upload additional files.) 

Please make sure your name and birthdate are listed on the documents. All files submitted will be placed into your medical chart.

Click Submit once you have uploaded the file.

Call Us:  (850) 231-9286