Intake Form | stephanieellis

Stephanie Ellis Wellness Therapies

is located at

Fifth Avenue Executive Centre

217 N. 5th Ave, Suite 101

Wilmington, NC 28401

call (910) 431-3325

email stephanie.ellis.lmbt@gmail.com

SCHEDULE NOW

If you are unable to keep your appointment, please cancel at least 24 hours in advance

or pay a $30 cancellation free.

Thank you for your consideration.

Are you a new client? Or has it been over a year since you have updated your information? Please complete this form to save time at your visit. Less time on forms = more time for you, yay!

HEALTH HISTORY INTAKE FORM

DISCLAIMER
Please note that Reiki and any other systems on this website are complimentary and will work in conjunction with any Western Medicine/Treatment you may be receiving, BUT they should never take the place of a licensed medical practitioner. If you suffer or believe you may be suffering from any medical, emotional or psychological issues always contact a licensed medical professional. The information contained in this website is for information purposes only and therefore Stephanie Ellis Wellness Therapies will not be held responsible for any actions taken as a result of the information provided on this website.

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Health History Intake Form

Please check if you currently have any of the following health concerns:

Back pain/Sciatica

Spinal problems

Osteoporosis

Recent broken bones or sprains

Skin problems

Varicose veins

Phlebitis/Blood clots

Tendonitis or bursitis

Arthritis or joint disease

Diabetes

Seizures

Multiple Sclerosis

Cancer

Numbness/tingling

Breathing difficulty

Fibromyalgia or Chronic Fatigue Syndrome

I understand that the services offered are not a substitute for medical care and that any information provided by the therapist is for educational purposes only and is not diagnostic or prescriptive in nature. The therapist reserves the right to refuse service to anyone for inappropriate behavior and for illness that are contraindicated for massage.

The client has the right to stop the session at any time. If I have any concerns I will speak to the therapist. If I experience any pain or discomfort during the session, I will immediately inform the therapist. The therapist assumes no responsibility for any items lost, or any damages incurred to property while at the office, any disclosed or undisclosed illness or personal injury.

I have stated all conditions that I am aware of on this form and this information is true and accurate. I will inform the therapist of any changes in my health status.

Thanks for submitting! All forms will remain 100% confidential.