Appointment Request Please complete the form below to schedule an appointment. I will try my best to accommodate your request and will be in touch ASAP. "To be yourself in a world that is constantly trying to make you something else is the greatest accomplishment." - Ralph Waldo Emerson Please enable JavaScript in your browser to complete this form.Name *Email *PhoneBy entering your phone number and checking this box, you agree to receive informational SMS messages (appointment reminders, account notifications, etc.) from us. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at sally@connecttherapiesllc.com. You may opt out at any time by replying STOP. Click here for Terms & Conditions / SMS Privacy Policy. Preferred Time and DateComment or MessageBy 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. *Yes, I want to submit this form & agree to the terms of use.NameSubmit
