Intake Form

July 5, 2017 by Eric Cho Leave a Comment

Intake Form

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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.

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Intake Form

Given the health and safety concerns surrounding the COVID-19 situation we are currently offering telehealth/video sessions to provide you with support during this challenging time.