Appointment Request Use this form to request an appointment. Please enable JavaScript in your browser to complete this form.Name *E-mail *Preferred Date & TimePhoneComment or MessageSMS/Texting Policy *Yes, I agreeBy checking this box, I agree to receive automated text messages for appointment reminders and feedback at this phone number: 212-970-8210. I understand that by checking the box, I will receive text (SMS) messages until I reply STOP and that I can reply HELP at any time to receive help. I further understand that message and data rates apply, and the message frequency will vary. I acknowledge that I have received and reviewed the Terms and Conditions and Privacy Policy provided.Terms of Use *Yes, I want to submit this formI agree with the Privacy Policy and Terms & Conditions 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.EmailSubmit
