(954) 716-6702
Schedule 15 Minute Consultation
roger@doctorlavine.com | (954) 716-6702

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"I have been through some terrible things in my life, some of which actually happened."

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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.


121 S. Orange Ave., Ste 1594
Orlando, FL 32801

roger@doctorlavine.com
(954) 716-6702

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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.