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. Optional SMS Consent: You agree to receive informational messages (appointment reminders, account notifications, etc.) from Just For Men Behavioral Health. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at info@justformenbh.com. You can opt out at any time by replying STOP. Messaging Terms and Conditions[https://justformenbh.com/terms-and-conditions] SMS & Privacy Policy[https://justformenbh.com/privacy-policy]