• Elysian Palms Naples

    New Massage Client Intake & Medical Consent

    All information is reviewed only by the therapist of Elysian Palms, Gaye Dabbs, LMT LE
  • Date
     - -
  • Format: (000) 000-0000.

  • Health Information

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  • 4. Frequency
  • 5. At what time of day is the pain at its worse?

  • Please check any symptoms that apply:

  • Head Symptoms
  • Neck Symptoms
  • Shoulders Symptoms
  • Arms & Hands Symptoms
  • Mid-Back Symptoms
  • Low Back Symptoms
  • Hip Symptoms
  • Legs and Feet Symptoms

  • Appointment

  • Elysian Palms Massage & Spa LLC
    Client Agreement & Consent
    With Gaye A. Dabbs, LMT


    Confidentiality Your information is private and secure. Written authorization is required to release any personal or medical details.

    Professional Standards I strictly follow Florida Department of Health Massage Therapy regulations, and the laws of Collier County and the State of Florida. Inappropriate behavior will not be tolerated and may be reported to local law enforcement. 

    Client Rights You may end the session at any time for any reason.

    Client Acknowledgment I understand that therapeutic massage is not a substitute for medical care, diagnosis, or treatment of illness, disease, or any physical or mental condition.
    I acknowledge that massage is designed to support myofascial care, pain relief, and the prevention of dysfunction. I agree to communicate any discomfort or pain immediately during the session.
    I have provided accurate medical information and will update the therapist of any changes in my health.
    By providing my electronic signature below, I agree to the policies and client agreement outlined above.

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