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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.

I do not consent to any solicitations or marketing inquiries to the contact provided, and that by hitting the submit button you affirm and agree that you are a prospective client looking for services. Thank you for honoring everyone's time.
Namaste.