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) First Last Patient/Child’s Name First Last Phone(Required)Email(Required) Consent I (Patient/Guardian) understand that some personal contact is required with (Patient/Child’s) to perform certain testing and activities.Patient/Guardian Signature(Required)