SMS Texting Opt-in

By entering your phone number and checking the box, you consent to receive SMS/MMS text messages from FirstStates at the number you provided. Message and data rates may apply. Message frequency varies. Upon receiving messages, you may reply STOP to unsubscribe or HELP for assistance. For help reply HELP to any message we send, or contact 866-328-7792 or support@firststates.com. To unsubscribe from receiving text communications, reply STOP at any time. Please review our Privacy Policy and Terms of Service for additional information.

By clicking "Submit," I acknowledge that I have read and understand this authorization and consent statement and agree to the use of my information as described above.

*By checking this box, I agree to receive text messages from FirstStates at the provided mobile number

*Patient / Authorized Representative Name

*Date