Please fill out the information on this page and click the submit button at the bottom. Do not leave this page or reload. You will lose all of your entries and will have to start over. Questions that do not apply to you can can be left blank. Once you click Submit please scroll back to the top of the page and you will receive confirmation that your registration has been submitted 

If you prefer, You can also print the paper forms and fill them out in advance. Click on the forms tab if you wish to use this method. You can also upload your id , insurance card, medication list etc. by clicking the forms tab above and following the instructions.

Once you have submitted your registration our staff will reach out to you to make your appointment. Please present your insurance and id card to our reception desk during your first appointment. 

Secure Online Registration

Coastal Family Practice

and Acute Care Center, LLC.

Call Us:  (850) 231-9286