Skip to main content
Home » Contact Us » Online Forms » Personal Contact Consent Form

Personal Contact Consent Form

Dear Patients,
During the course of Primitive Reflex Testing, Vision Therapy Testing as well as Vision Therapy Sessions, the therapists may have personal contact with you/your child (ie...head, back, lower legs, shoulders). By signing this form you are consenting to personal contact.
Patient/Guardian Name(Required)
Patient/Child’s Name
Consent