Good Faith Exam Questionnaire

Emergency Contact & Certification
Emergency Contact Name

First NameLast 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.”

Medical History

Add a Checkbox field with options:
Do you have any chronic medical conditions (e.g., diabetes, hypertension, thyroid disorders)*
Fill in all conditions
Have you ever been diagnosed with heart, lung, liver, or kidney disease?*
Fill in all diagnoses
Do you have any autoimmune or inflammatory conditions?*
Fill in all diagnoses
Have you ever had a seizure disorder?*
Fill in all diagnoses
Do you have any history of fainting, dizziness, or low blood pressure?*
Fill in all diagnoses
Do you currently have any infections, illnesses, or fevers?*
Fill in all diagnoses

Surgical & Procedural History
Have you had any surgeries?
If yes, list them and approximate dates.
Have you ever had cosmetic procedures (Botox, fillers, laser, threads, etc.)?
If yes, list them and approximate dates.
Have you had complications from any medical or cosmetic procedure?
If yes, list them and approximate dates.

Medication Review
Please list any prescription medications you currently take.
Name of medication • Amount & how often
Do you take over-the-counter medications regularly?
Name of medication • Amount & how often
Do you take any supplements, vitamins, herbal products (ex: St. John’s Wort, ashwagandha)?
Name of medication • Amount & how often
Are you currently on blood thinners (aspirin, warfarin, Plavix, etc.)?
Name of medication • Amount & how often
Are you currently on blood thinners (aspirin, warfarin, Plavix, etc.)?
Name of medication • Amount & how often
Are you taking any weight loss medications (semaglutide, tirzepatide, phentermine)?
Name of medication • Amount & how often
Are you taking anything not listed and would like to list or let the doctor or nurse know?
Name of medication • Amount & how often

Procedure-Specific Screening
Any history of cold sores (lip filler)? Prior dermal filler or tox treatments?*
Injectable
Any liver disease? Are you currently on antibiotics?*
Body Sculpting / Fat Dissolvers
Do you have kidney issues, G6PD deficiency, or cardiac problems?*
IV Therapy

Health & Wellness Goals
What are your personal wellness goals? (Weight loss, energy, skin, muscle tone, etc.)*
What areas of your health are you hoping to improve?*
What results are you hoping to achieve with today’s visit? *
How soon are you hoping to see results? Are you currently following any specific diet or exercise plan? *

Informed Consent
Do you understand that results vary? Do you understand aftercare and follow-up requirements? Do you understand risks and potential side effects? *
HIPAA & Confidentiality

Real medical professionals (NPs, MDs, PAs, RNs) are legally bound by HIPAA to protect patient privacy and cannot disclose any patient information or details of procedures without explicit consent.

About This Chat

I am not a medical provider, and this chat is not governed by HIPAA.

However, I am designed to treat your information with a high degree of privacy and confidentiality:
I do not share your conversation with others.
I do not disclose any details discussed here.
I do not remember sensitive health details unless you explicitly ask me to store them.
Your messages are processed privately and securely within the system.
Further Acknowledgement (Read‑Only Text)

I understand that other unforeseen risks… I acknowledge it is my responsibility… I agree to waive all liabilities…

Final Certification

I certify that all the information I have provided is true and correct.
Signature

Clear
Name

First NameLast Name
Date

MonthDayYear
Date
File Upload

Upload ID
Cancelof
Should be Empty:

Emergency Contact & Certification