Good Faith Exam (GFE) – Aesthetic Medicine
Dr. Elliot Heller, MD
Section 1: Patient Information
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
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
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.
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
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Section 2: Chief Complaint / Reason for Visit
Section 3: Medical History
A. Past Medical Conditions (check all that apply):
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:
Skin Conditions (check all that apply):
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:
B. Surgical History:
C. Allergies (including lidocaine, botulinum toxins, fillers):
D. Current Medications:
E. Supplements / Herbal Products:
F. History of Cosmetic Procedures / Complications:
G. Have you taken antibiotics within the past 2 weeks?
Yes
No
H. Have you used Accutane (isotretinoin) in the past 6 months?
Yes
No
Section 4: Skin Care Habits / Topical Treatments
Retinol / Tretinoin:
Yes
No
Alpha Hydroxy Acids (AHAs) (Glycolic, Lactic, Mandelic acids):
Yes
No
Beta Hydroxy Acids (BHAs) (Salicylic acid):
Yes
No
Vitamin C / Antioxidants:
Yes
No
Hydroquinone / Brightening agents:
Yes
No
Moisturizers / Emollients:
Yes
No
Sunscreen daily:
Yes
No
Other skincare products:
Section 5: Social History
Tobacco Use:
Yes
No
Other
If Other, please describe:
Alcohol Use:
Yes
No
Other
If Other, please describe:
Recreational Drugs:
Yes
No
N/A
Details:
Section 6: Review of Systems (ROS)
Denies fever, rash, shortness of breath, or chest pain
Denies pregnancy or breastfeeding
Other pertinent positives/negatives
Section 7: Physical Examination
General:
Well-appearing
Distressed
Skin:
Facial Assessment:
Other Findings:
Section 8: Assessment / Impression
Diagnosis / Condition(s):
Select all that apply:
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:
Section 9: Plan of Care (POC)
Type a question
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:
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
Yes
Patient questions answered
Yes
Section 10: Informed Consent
Separate informed consent forms for specific procedures reviewed and signed
Yes
Patient verbalized understanding of treatment plan and limitations
Yes
Section 11: Signatures
Patient Signature
Date
-
Month
-
Day
Year
Date
Provider Name
First Name
Last Name
Provider Signature
Date
-
Month
-
Day
Year
Date
Submit
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