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.

By submitting this form via this web portal, I consent to have staff at Ho'oulu Counseling communicate with me by standard SMS messaging regarding various aspects of my health information, which may include but is not limited to appointments and billing. I acknowledge and accept the risks of communicating your health information via standard SMS 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.