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. Use of this website to submit information may not be completely secure or HIPAA compliant. The use of the Internet or this form for communication with our Company or any individual member of our Company does not establish a professional relationship. Confidential or time-sensitive material should not be submitted using this form and there is not a guarantee of a response time or a response at all, although we do our best to respond to each inquiry. Submitting this form confirms my understanding.