Appointment Request

Appointment Request

Please complete the form below to schedule an appointment. Jacob will do his best to accommodate your request and will be in touch with you as soon as possible.

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.