Good Faith Exam (GFE) – Aesthetic Medicine
Dr. Elliot Heller, MD
Section 1: Patient Information
Patient Name
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First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Age
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact
Emergency Contact Name Please list an emergency contact we may contact in the event of a medical or other emergency. By providing this information, you authorize us to disclose relevant health information as necessary for your care and safety.
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First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Section 2: Chief Complaint / Reason for Visit
Reason for visit
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Section 3: Medical History
A. Past Medical Conditions (check all that apply):
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Diabetes
Heart Disease
Autoimmune Disorder
Bleeding Disorder
Neuromuscular Disorder
Thyroid Disorder
HSV 1 or 2
Pacemaker
Implants/Metal Implants
None
Other
If Other, please describe (write N/A if not applicable):
*
Skin Conditions (check all that apply):
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Acne
Rosacea
Eczema / Atopic Dermatitis
Psoriasis
Hyperpigmentation
Hypopigmentation
Keloid / Hypertrophic Scarring
Skin cancer or family history of skin cancer
Other (please explain below)
None
If Other, please describe (write N/A if not applicable):
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B. Surgical History:
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C. Do you have any known drug allergies?
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Yes
No
C2. Do you have any allergy or sensitivity to anesthetic/numbing medication- topical or injectable? ?
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Yes
No
C3. Please list all Allergies (including lidocaine, botulinum toxins, fillers):
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D. Current Medications:
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E. Supplements / Herbal Products:
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F. History of Cosmetic Procedures / Complications:
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G. Have you taken antibiotics within the past 2 weeks?
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Yes
No
H. Have you used Accutane (isotretinoin) in the past 6 months?
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Yes
No
Section 4: Skin Care Habits / Topical Treatments
Are you currently using or have you recently used any of the following?
Retinol / Tretinoin:
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Yes
No
Alpha Hydroxy Acids (AHAs) (Glycolic, Lactic, Mandelic acids):
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Yes
No
Beta Hydroxy Acids (BHAs) (Salicylic acid):
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Yes
No
Vitamin C / Antioxidants:
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Yes
No
Hydroquinone / Brightening agents:
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Yes
No
Moisturizers / Emollients:
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Yes
No
Sunscreen daily:
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Yes
No
Other skincare products:
*
Section 5: Social History
Tobacco Use:
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Yes
No
Other
If Other, please describe:
Alcohol Use:
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Yes
No
Other
If Other, please describe:
Recreational Drugs:
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Yes
No
Details:
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Section 6: Review of Systems (ROS)
Denies fever, rash, shortness of breath, or chest pain
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Denies pregnancy or breastfeeding
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Other pertinent positives/negatives
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Section 7: Physical Examination
General:
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Well-appearing
Distressed
Skin:
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Facial Assessment:
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Other Findings:
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Section 8: Assessment / Impression
Diagnosis / Condition(s):
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Select all that apply:
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Fine lines/ Wrinkles
Loss of skin elasticity
Volume loss / Facial atrophy
Acne scars
Hyperpigmentation / Melasma
Hypopigmentation
Rosacea / Redness
Keloid / Hypertrophic scarring
Uneven skin texture
Other
If Other, please explain:
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Section 9: Plan of Care (POC)
Type a question
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Neurotoxins
Dermal Fillers
Sculptra
PRP / PRF
Chemical Peels
SkinPen / RF Microneedling (Morpheus8)
Sofwave
Topical Exosomes (Rejuran, Benev, etc.)
DermaV Laser
Weight-Loss Injections (GLP-1, etc.)
Vitamin Shot
IV Vitamin Infusion
Other
If Other, please explain:
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Recommended Treatments Based on Diagnosis:
For Fine lines / Wrinkles:
Neurotoxins– relax dynamic facial wrinkles (forehead, glabella, crow’s feet); repeat every 3–4 months
Dermal Fillers – smooth static wrinkles and restore volume
Sculptra® – stimulate collagen and restore facial volume
Sofwave® – high-intensity ultrasound for skin tightening
Topical Exosomes (Rejuran® or Benev®) – improve texture and hydration
DermaV Laser – reduce fine lines and improve skin tone
SkinPen / RF Microneedling (Morpheus8) - stimulate collagen and restore facial volume
For Volume Loss / Facial Atrophy/Skin Elasticity:
Dermal Fillers – restore facial volume and contour
Sculptra® – series of 2–3 treatments spaced 4–6 weeks apart
Sofwave® – single session with follow-up at 12 weeks
For Medical Weight Loss
Tirzepatide/L-Carnitine Injections (weekly)
2.5 mg = 25 units (0.25 ml)
5 mg = 50 units (0.5 ml)
7.5 mg = 75 units (0.75 ml)
10 mg = 100 units (1 ml)
12.5 mg = 125 units (1.25 ml)
15 mg = 150 units (1.5 ml)
For Hyperpigmentation/Sun Damage/Melasma:
DermaV Laser –Improve skin tone
Chemical Peel – reduce fine lines and improve skin tone
Topical Regimen (details below)
For Vitamin Deficiency/Longevity:
B12 Methylcobalamin 5mg
Vitamin D3 50,000IU inj
Glutathione 200mg
NAD+ Injection 100 mg
Lipo Plus B6 2mg, Methionine 12.4mg, Inositol 25mg, Choline 25mg
Details of Topical Regimen:
Home Skin Care Recommendations:
Broad-spectrum sunscreen SPF 30+ daily
Topical retinol/tretinoin at night (if not contraindicated)
Other Recommendations: see details below
Other Recommendations explained:
Risks, benefits, and alternatives discussed
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Yes
Patient questions answered
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Yes
Section 10: Informed Consent
Separate informed consent forms for specific procedures reviewed and signed
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Yes
Patient verbalized understanding of treatment plan and limitations
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Yes
Section 11: Signatures
Patient Signature
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Date
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Month
-
Day
Year
Date
Provider Name
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First Name
Last Name
Provider Signature
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Date
*
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Month
-
Day
Year
Date
Submit
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