Akimat Wellness – Intake Form

Thank you for booking!

For your safety and the best experience, please complete your intake form before your appointment. This helps us customize your service and ensure your comfort.

See you soon!
The AKIMAT Team

Client Information

(Required for all services)

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Emergency Contact

(###)

###

####

Service Selection

Select your appointment service

Universal Consent

Checkbox

Consent Agreement

I confirm my information is accurate and consent to treatment.

How did you hear about us?

Social Media

Friend/Family

Google Search

Instagram

Google Maps

Bayonne