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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. *

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“Alone We Can Do So Little; Together We Can Do So Much.” - Helen Keller

“Alone We Can Do So Little; Together We Can Do So Much.”
- Helen Keller