模板 同意书 护肤同意书模板

护肤同意书模板

护肤同意书模板

使用现成模板，30 秒即可创建问卷。选择模板、自定义内容，然后轻松分享并收集答卷。
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14
题
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Skincare Consent Form Template

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*
Full Name
*
Date of Birth
*
Email Address
*
Phone Number
*
Primary Skin Concerns [多选题]
Acne / Frequent Blemishes
Fine Lines / Wrinkles / Aging
Dark Spots / Hyperpigmentation / Uneven Tone
Redness / Rosacea / Broken Capillaries
Extreme Dryness / Dehydration
High Sensitivity / Easily Irritated
*
Are you currently using any of the following ingredients in your daily routine? [多选题]
Retinol / Retin-A / Tretinoin / Tazorac
Alpha Hydroxy Acids (AHAs) (e.g., Glycolic, Lactic, Mandelic Acid)
Beta Hydroxy Acids (BHAs) (e.g., Salicylic Acid)
Benzoyl Peroxide
Hydroquinone (Skin lightening creams)
None of the above
*
Have you taken Accutane (Isotretinoin) within the last 6 to 12 months?
Yes
No
*
Medical Conditions & Contraindications [多选题]
Pregnant or currently nursing
History of cold sores / Herpes Simplex flare-ups
Active Eczema, Psoriasis, or Dermatitis on the face
Prone to Keloid scarring
Autoimmune disease (e.g., Lupus, Scleroderma)
Diabetes (Can affect skin healing times)
None of the above
*
Have you received any of these treatments recently? [多选题]
Facial Waxing, Sugaring, or Threading (within the last 5 days)
Chemical Peel (within the last 2 weeks)
Laser Skin Resurfacing or IPL (within the last 4 weeks)
Cosmetic Injectables / Botox / Dermal Fillers (within the last 2 weeks)
None of the above
*
Do you have any known allergies? (Particularly to aspirin, latex, nuts, fruits, or synthetic fragrances)
Yes (Please specify)
No
*
Informed Consent & Disclaimers [多选题]
I understand that skincare treatment results vary by individual. No specific outcome or cure can be 100% guaranteed.
I acknowledge that temporary side effects can include redness, mild swelling, flaking, peeling, stinging, or irritation, which usually fade within a few days.
I agree to follow the post-treatment care instructions provided by my esthetician, including daily application of SPF 30+ and avoiding direct sun exposure.
I affirm that all information provided in this form is accurate to the best of my knowledge, and I have not withheld any medical history.
*
Do you consent to before-and-after photographs being taken of your treatment area?
Yes, for both clinical files and marketing purposes. (Photos may be shared on social media, but my eyes/identifying features will be blurred if requested).
Yes, for clinical records ONLY. (Photos will remain strictly confidential in my secure digital file to track skin progress).
No, I do not consent to any photographs.
*

Signature

请在以下矩形区域内绘制
清空撤销橡皮擦确定并上传
*
Date Signed
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模板介绍

护肤同意书模板是一款专业的入案工具，专为美容院、皮肤科诊所和护肤工作室设计，用于收集客户健康信息并在面部或美容治疗前获得服务同意。


它涵盖皮肤过敏史、敏感疾病、持续用药记录以及清晰的责任确认选项，包含简洁的填写和多项选择部分。定制护理产品、禁忌提醒和护理后责任声明，适用于面部护理、换肤和激光护肤程序，然后在预约前与客户分享表格。


所有提交的表格通过记录所有护肤服务的知情同意，保护服务提供者和客户。


点击“使用此模板”以简化您的沙龙接待流程，并标准化安全、合规的护肤服务授权。

3 个简单步骤即可开始

1

使用这个模板

点击“使用此模板”即可在 SurveyMars 中打开。无需注册，也能预览和测试。

2

自定义您的问卷

编辑题目、上传 Logo，并将设计调整为符合您的品牌。无需技术能力，也能创建专业问卷。

3

分享并收集答卷

通过链接、二维码或嵌入网站分享。答卷提交后，会立即显示在您的仪表盘中。

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