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10 Crow Canyon Court, Suite 101, San Ramon, CA 94583

447 Sutter St., 3rd Floor, Ste, 319, San Francisco, California 94108

    Please know that electronic communication or messaging via this web portal is not encrypted. There is a possibility that information you include in your submission can be intercepted and read by parties other than the intended recipient. To protect your privacy, please do not include personal medical information in your submission. Alternatively, you may call us at 925-665-3668.

    By including personal medical information in this form and submitting it via this web portal, you acknowledge and accept the above risks of communicating such information through an unencrypted and unsecured electronic method. By clicking "Yes, I want to submit this form and agree to the terms of use" and submitting this form, you agree to hold Brighter Vision, its respective officials, directors, employees, members and agents harmless from and against any and all damages, claims, obligations, and liabilities arising out of any unauthorized use of, disclosure of, or access to your personal health information included and submitted via this web portal.