Name *

First Name

Last Name

Phone

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Yes I am a potential client and not a solicitor.

I understand that Drew does not participate in any insurance panels

I am aware that limited sliding by scale fee spots are available and are based on need

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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.

Yes, I want to submit this form