Good Faith Exam Questionnaire
Contact Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of birth
01/01/2021
Referred By
Christianna Raje
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Emergency Contact & Certification
Emergency Contact Name
First Name
Last Name
Emergency Contact
Please enter a valid phone number.
Read-only statement
I hereby certify that I have explained to the patient the nature, purpose, benefits, risks of and alternatives to the procedure, have offered to answer any questions and have fully answered such questions.”
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Medical History
Add a Checkbox field with options:
Anemia/pernicious anemia
Yes
No
Asthma
Yes
No
Blood Disorder
Yes
No
Cancer/Chemotherapy
Yes
No
Diabetes
Yes
No
Celiac or Crohn’s Disease
Yes
No
Fatigue
Yes
No
G6PD deficiency
Yes
No
Heart Disease
Yes
No
Hemochromatosis
Yes
No
Immunosuppressant
Yes
No
Irritability/moodiness
Yes
No
Kidney disease
Yes
No
Liver disease
Yes
No
Low/depressed mood
Yes
No
Memory issues
Yes
No
None
None of the above
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Allergies
Do you have any known allergies? Including Biotin.
Yes
No
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Further Acknowledgement (Read‑Only Text)
I understand that other unforeseen risks… I acknowledge it is my responsibility… I agree to waive all liabilities…
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Final Certification
I certify that all the information I have provided is true and correct.
Signature
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Please upload a photo of • DL / ID / Passport
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