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Beauty and skincare · Form

Sample فرم پذیرش ویزیت پوست

نوع پوست، مشکل اصلی، روتین فعلی و حساسیت‌ها پیش از ویزیت.

10 questions · Free up to 50 responses a month

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About this template

“فرم پذیرش ویزیت پوست” has 10 questions; 5 are required and 5 optional. Question types: Short text (2), Yes / No (2), Mobile number (1), Number (1), Single choice (1), Multiple choice (1), Long text (1), File upload (1). 11 ready-made options across 2 choice questions, all editable in the online version.

In the online version of this template

  • Mobile numbers are validated against the Iranian number format.
  • Attached files are stored with the response.
Related:Online form builder

Questions in this template

  1. 1.

    نام و نام خانوادگی *

    (Short text)
  2. 2.

    شماره موبایل *

    (Mobile number)
  3. 3.

    سن

    (Number)
  4. 4.

    نوع پوست *

    (Single choice)
    • خشک
    • چرب
    • مختلط
    • نرمال
    • حساس
  5. 5.

    مشکل اصلی *

    (Multiple choice)
    • جوش
    • لک
    • چین‌وچروک
    • منافذ باز
    • قرمزی
    • خشکی
  6. 6.

    روتین فعلی (محصولاتی که استفاده می‌کنید)

    (Long text)
  7. 7.

    داروی پوستی یا خوراکی مصرف می‌کنید؟ *

    (Yes / No)
  8. 8.

    کدام داروها؟

    (Short text)
  9. 9.

    باردار یا شیرده هستید؟

    (Yes / No)
  10. 10.

    عکس بدون آرایش در نور طبیعی

    (File upload)

Printable or online?

Printable version (Word & PDF)

  • For filling in on paper, signing and filing by hand
  • Edit the Word file any way you like
  • Collecting and typing up the answers is up to you
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Online version on Porsino

  • Answers are collected and organised automatically — no retyping
  • National ID, mobile number and dates are validated instantly
  • Ready-made reports and charts, plus Excel export in one click
  • Share a link or QR code — it works on mobile too
Build the online version for free

How do I use this template?

  1. Sign up for Porsino for free; no bank card needed.
  2. In the panel, open “Templates” and choose “فرم پذیرش ویزیت پوست”.
  3. Change the questions as you like, publish the form and send the link.

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