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<div class="wpforms-container wpforms-container-full" id="wpforms-3874"><form id="wpforms-form-3874" class="wpforms-validate wpforms-form" data-formid="3874" method="post" enctype="multipart/form-data" action="/" data-token="ceb7dbcd981222da2146de734a75d2b2"><noscript class="wpforms-error-noscript">Please enable JavaScript in your browser to complete this form.</noscript><div class="wpforms-field-container"><div id="wpforms-3874-field_0-container" class="wpforms-field wpforms-field-name" data-field-id="0"><label class="wpforms-field-label" for="wpforms-3874-field_0">Your Name <span class="wpforms-required-label">*</span></label><input type="text" id="wpforms-3874-field_0" class="wpforms-field-large wpforms-field-required" name="wpforms[fields][0]" required></div><div id="wpforms-3874-field_3-container" class="wpforms-field wpforms-field-text" data-field-id="3"><label class="wpforms-field-label" for="wpforms-3874-field_3">Subject</label><input type="text" id="wpforms-3874-field_3" class="wpforms-field-large" name="wpforms[fields][3]" ></div><div id="wpforms-3874-field_1-container" class="wpforms-field wpforms-field-email" data-field-id="1"><label class="wpforms-field-label" for="wpforms-3874-field_1">Your Email <span class="wpforms-required-label">*</span></label><input type="email" id="wpforms-3874-field_1" class="wpforms-field-large wpforms-field-required" name="wpforms[fields][1]" required></div><div id="wpforms-3874-field_2-container" class="wpforms-field wpforms-field-textarea" data-field-id="2"><label class="wpforms-field-label" for="wpforms-3874-field_2">Your Message <span class="wpforms-required-label">*</span></label><textarea id="wpforms-3874-field_2" class="wpforms-field-small wpforms-field-required" name="wpforms[fields][2]" required></textarea></div><div id="wpforms-3874-field_5-container" class="wpforms-field wpforms-field-checkbox" data-field-id="5"><label class="wpforms-field-label" for="wpforms-3874-field_5">Terms of Use <span class="wpforms-required-label">*</span></label><ul id="wpforms-3874-field_5" class="wpforms-field-required"><li class="choice-1 depth-1"><input type="checkbox" id="wpforms-3874-field_5_1" name="wpforms[fields][5][]" value="Yes, I want to submit this form" required ><label class="wpforms-field-label-inline" for="wpforms-3874-field_5_1">Yes, I want to submit this form</label></li></ul><div class="wpforms-field-description wpforms-disclaimer-description">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.</div></div></div><div class="wpforms-field wpforms-field-hp"><label for="wpforms-3874-field-hp" class="wpforms-field-label">Email</label><input type="text" name="wpforms[hp]" id="wpforms-3874-field-hp" class="wpforms-field-medium"></div><div class="wpforms-submit-container" ><input type="hidden" name="wpforms[id]" value="3874"><input type="hidden" name="wpforms[author]" value="2"><input type="hidden" name="wpforms[post_id]" value="5"><button type="submit" name="wpforms[submit]" class="wpforms-submit " id="wpforms-submit-3874" value="wpforms-submit" aria-live="assertive" data-alt-text="Sending..." data-submit-text="Submit">Submit</button></div></form></div> <!-- .wpforms-container -->