By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.
Please note this form is not for emergencies or pharmacy refills or requests. If this is a mental health or medical emergency, please call 911. If this is a prescription request or question for a current patient, please call our office directly during business hours.