Appointment Request

Appointment Request

Please complete the form and submit your information.
We will try our best to accommodate your request as soon as possible.

"New beginnings are often disguised as painful endings"
~ Lao Tzu

By submitting this form via this web portal, you acknowledge and accept that 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.