Call Us:  (850) 231-9286

Coastal Family Practice

and Acute Care Center, LLC.

Patient Name: _______________________________________________________________________

Mobile Phone Number: ______________________________________________________________

Consent to Receive Text Messages

By providing your mobile number and signing below, you agree to receive text messages from Coastal Family Practice and Acute Care Center, LLC. for purposes including, but not limited to: 

• Appointment reminders 
  
• Follow-up care instructions 
  
• General health-related communications
  

Message Frequency: Varies based on your care and appointments

Message & Data Rates: Standard message and data rates may apply

Privacy Assurance:

We respect your privacy. Your mobile number and personal information will not be sold or shared with third parties for marketing purposes.

Opt-Out Instructions:

You may opt out of receiving text messages at any time by replying STOP to any message. For help, reply HELP or contact our office at 850-231-9286.

Acknowledgment & Consent:

By signing below, you confirm that: 

• You are the authorized user of the mobile number provided 
• You consent to receive SMS messages from Coastal Family Practice and Acute Care Center, LLC. 
  
• You understand you can opt out at any time
  

Signature: ________________________________________________________________________________

Date: ________/__________/_________________

Please print page and submit form directly to our office or you can fax to 850-231-9287 Attention: Robert Marshall Privacy Officer.  You can also email form to Robert Marshall Privacy Officer at rmarshall@coastalfamilypractice.net

SMS Communication Consent Form