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護膚同意書範本

護膚同意書範本

使用現成範本，30 秒即可建立問卷。選擇範本、自訂內容，然後輕鬆分享並收集回覆。
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10,000+
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✓ 無須信用卡
✓ 問卷、題目和回覆數量無限制
14
題
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Skincare Consent Form Template

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*
Full Name
*
Date of Birth
*
Email Address
*
Phone Number
*
Primary Skin Concerns [多選題]
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? [多選題]
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 [多選題]
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? [多選題]
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 [多選題]
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

請在以下矩形區域內繪製
清空撤銷橡皮擦確定並上傳
*
Date Signed
image result
範本介紹

護膚同意書範本是一套專業的入門工具，專為美容院、皮膚科診所及護膚工作室設計，用以收集客戶健康資訊，並在臉部或美容療程前取得服務同意。


它涵蓋皮膚過敏史、敏感狀況、持續用藥紀錄及明確的責任確認選項，包含簡明的填寫與多選題部分。客製化臉部護理、換膚及雷射護膚的護理項目、禁忌提醒及術後責任聲明，並在預約前與客戶分享表格。


所有提交的表格都透過記錄所有護膚服務的知情同意，保護服務提供者與顧客。


點擊「使用此範本」以簡化您的沙龍接待流程，並標準化安全且合規的護膚服務授權。

3 個簡單步驟即可開始

1

使用這個範本

點選「使用此範本」即可在 SurveyMars 中開啟。無須註冊，也能預覽和測試。

2

自訂您的問卷

編輯題目、上傳標誌，並將設計調整為符合您的品牌。無須技術能力，也能建立專業問卷。

3

分享並收集回覆

透過連結、QR Code 或嵌入網站分享。回覆送出後，會立即顯示在您的儀表板中。

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