Free printable template · PDF
Good Faith Exam Form
A one-page good faith exam form for the provider who assesses a patient before aesthetic treatment. It records what was reviewed, what was found, which treatments are approved and with what limits, and how long the approval lasts.
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Good Faith Exam Form
MedSpaBinder
Patient name
Date of birth
Exam date
Your state decides who may perform a good faith exam and whether it can be done by telehealth. Your medical director sets its content.
Exam type
In person
Telehealth (video)
Renewal of a previous exam
Treatments requested / patient's goals
History reviewed
Allergies (including to anesthetics)
Current medications and supplements
Blood thinners or bleeding disorders
Pregnant or breastfeeding
Neuromuscular conditions
Autoimmune conditions
History of cold sores
Keloids or poor healing
Infection or rash in the treatment area
Previous treatments and any complications
Findings and notes
Treatments approved
Contraindications / not a candidate for
Provider name and credentials
Exam valid until
Provider signature
Date and time
What a good faith exam is
A good faith exam (GFE) is the medical assessment a licensed provider does before a patient's first aesthetic medical treatment, and periodically after. It establishes that treatment is appropriate: the history has been reviewed, contraindications ruled out, and the specific treatments approved. In many states it's what allows nurses and other staff to treat under a physician's orders.
What varies by state
- Who may perform it: a physician in some states; an NP or PA in others.
- Whether it can be done by telehealth, and what that visit must include.
- How long it stays valid before a new exam is needed.
- What must be documented. Your medical director may ask for more than this form has.
How to use this form
- Complete it before the first treatment, and again when it expires or the patient's health changes.
- Approve treatments individually, with any limits, such as areas, products or maximum doses.
- File it in the patient's chart. Chart audits check for it.
Questions
How long is a good faith exam valid?
It depends on your state and your medical director. Many clinics renew it yearly, and sooner if the patient's health or medications change. Write the expiry date on the form.
Can a registered nurse perform the good faith exam?
In most states, no: it has to be done by a physician, NP or PA. Check your state's medical and nursing board rules before relying on any template.
General guidance, not legal or medical advice. Requirements vary by state; follow your medical director and product labels.