Email is not a secure form of communication. If this is a crisis,
please dial 911, or if you are in Franklin County call Netcare at 614-276-2273, or go to your nearest emergency room.
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.