Appointment Request

Please use the form below to request an appointment.

Name *

If inquiry is for a minor please provide their age

E-mail *

What is your Insurance type? ( we don't need the ID number at this point, just the brand) *

Phone Number *

Appointment Availability (Days and Times) *

Appointment Preference *

In Office
Telehealth
No Preference (this will allow the quickest appointment availability)

Message or Comment

How did you hear about us? *

Yes, I want to submit this form

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.

Comment