Good Faith Exam Form Template for Med Spas (2026)

A template, not legal advice. This page describes how a good faith exam record is usually structured and what each part is for. It does not set a clinical standard and does not state what any particular state requires. Your medical director should approve the final form, and healthcare counsel licensed in your state should review it before it goes into use.

Most med spas that get the good faith exam wrong do not skip it outright. They record it badly: a signature at the bottom of an intake packet, a checkbox that says "GFE complete," or a telehealth vendor's PDF that names no examiner. A reviewer reading that record later cannot tell whether a real evaluation happened, so as far as the file is concerned, it did not.

This page is about that record and nothing else. It is a working outline of the good faith exam form: the fields it needs, what belongs in each one, how to complete it at the visit, and how to file it so it can be found and understood years later. The legal questions sit on a different page. For which states require a GFE and who can perform it, including where remote examination is and is not settled, use our state-by-state guide; every statement below about examiners and telehealth defers to it.

What Does a Good Faith Exam Record Have to Document?

A good faith exam record has to show, to a stranger reading it later, that a specific practitioner with authority to do so evaluated a specific patient before treatment, what they considered, what they concluded, and exactly what they authorized. If the form cannot answer who, when, how, what was found, and what was ordered, it is not doing its job, however polished it looks.

In practice that means the form carries the following, each in its own field rather than buried in a paragraph:

1. Patient identifiers that tie the record to one person and one chart.
2. The examiner's name and credential, so a reader can see who made the decision and whether they were permitted to make it.
3. Date, time and modality, recording when the evaluation happened and whether it was in person or by telehealth.
4. History and current medications, as reviewed by the examiner rather than merely collected from the patient.
5. Allergies, recorded on their own line, including the "none known" answer when that is the answer.
6. Relevant exam findings for the treatment being considered.
7. Contraindications reviewed, showing what was considered and ruled out.
8. Assessment of candidacy: the examiner's conclusion, which may be yes, no, not yet, or yes with modifications.
9. Treatment(s) authorized, named specifically enough to act on.
10. Standing-order or protocol reference, identifying the document that governs any later administration within the authorized course.
11. Examiner signature, from the person who did the exam, dated and timed.

Two things are deliberately missing from that list. The first is anything a patient fills in on their own. Intake history is an input to the exam, not part of it, and our med spa intake form template covers that separate document. The second is clinical policy: dosing ranges, re-exam schedules, waiting periods and similar rules. Those belong in protocols your medical director signs.

The Good Faith Exam Form, Field by Field

The outline below is a skeleton to hand to your medical director or whoever drafts your documents. Each row is one section of the form; it contains no finished legal wording.

Patient identifiers

Use at least two identifiers, typically the full legal name and date of birth, plus the chart number your system assigns. The aim is that no reader could mistake whose evaluation this is, even if the page became separated from the rest of the record. If your practice uses a preferred name, record both; the legal name is what will match a pharmacy record or a complaint file.

Examiner name and credential

This field answers the question every reviewer asks first: who made the decision? Record the examiner's printed name, credential (for example MD, DO, PA or NP), licence number and the state that issued it. A signature alone is not enough; a reader should not have to decode one to learn who was responsible.

Who is allowed to fill this field is a legal question, and it is the one most often answered wrongly. Our good faith exam by state guide finds the same short list across every state it covers: a physician, a physician assistant within their practice or delegation agreement, or a nurse practitioner or APRN within their state's practice authority. It finds no covered state in which a registered nurse may perform the exam, and medical assistants, estheticians and other unlicensed staff never can. The form should make that visible. A credential drop-down limited to the roles your state and your medical director permit is better than a free-text box that will eventually be filled with "RN."

Date, time and modality

Record the date and the start time of the evaluation, and choose the modality from a fixed list: in person, or telehealth with the platform named. If the encounter was remote, record where the patient was physically located and where the examiner was, because licensure follows the patient's location and a reviewer will check it. The time matters more than most operators expect. It is how a reader confirms that the exam happened before treatment, not after it, and it is what reveals a workflow in which the exam is a click rather than an encounter.

Whether a telehealth exam is acceptable for a given treatment is set by state rules, not by your form. The section on telehealth documentation below covers what to record when it is allowed.

History and current medications

The patient's intake form collects the raw information. The good faith exam form records that the examiner reviewed it and noted what mattered for this decision. A practical structure is a "history reviewed" line pointing to the intake by date, then a free-text field for what the examiner considered relevant, including anything the patient added in conversation.

Current medications and supplements deserve their own sub-field. Record what the patient is taking, and the examiner's note on whether any of it affects the plan. A list copied from the intake with no indication it was read is the single most common weakness in this section.

Allergies

Give allergies a dedicated field, separate from history, with space for the agent and the reaction. Require an explicit entry: either the allergies themselves or "no known allergies," entered by the examiner. A blank field cannot be distinguished from a question nobody asked. If the treatment involves products or anaesthetics with known allergy considerations, your medical director may want the form to prompt for them by name; that list belongs in the protocol, and the form simply mirrors it.

Relevant exam findings

This is the field that proves an examination happened. It should hold what the examiner observed for the treatment being considered, written in the examiner's own words. The appropriate depth depends on the treatment and is a clinical question for your medical director; a neurotoxin consultation, a filler consultation and a weight-management evaluation will each look different. What matters for the document is that the findings are specific to this patient and this visit.

Resist the temptation to build this field as a set of pre-checked normal findings. A form that defaults to "within normal limits" across every box produces identical records for every patient, which a reviewer reads as no examination at all. Structured prompts are fine; pre-filled answers are not.

Contraindications reviewed

List the contraindications and precautions your medical director's protocol identifies for each service, and have the examiner record a finding against each one: absent, present, or present but managed with a note. This converts a vague "contraindications reviewed" checkbox into a record of what was actually considered. Keep the list itself in the protocol so it can be updated in one place; the form pulls from it rather than hard-coding clinical content that will go stale.

Assessment of candidacy

The assessment is the decision, and it should read like one. Offer four outcomes rather than a single "approved" box: a candidate; not a candidate; deferred pending more information or a change in circumstances; or a candidate with modifications to what was requested. Follow it with a short rationale in the examiner's words. Patient preference is a reason to consider treatment, not an indication on its own, so a rationale that says only "patient requests" is weak.

The "not a candidate" and "deferred" options matter even if they are rarely used. A practice whose records show the examiner occasionally declining or modifying a request has evidence that the evaluation is real. A practice whose records show every patient approved for everything has the opposite.

Treatment(s) authorized

This field is the patient-specific order, and it needs to be specific enough that the person administering the treatment can act on it without making a clinical decision of their own. Name the product or service, the treatment area, and whatever dose, units, volume or device parameters the examiner sets or bounds. Where more than one treatment is authorized, list each on its own line. Anything not listed is not authorized by this record.

Where the examiner and the administering provider differ, which is common, leave room for the administering provider's name and the time of administration, or point to the treatment record.

Standing-order or protocol reference

Name the standing order or protocol that will govern administration and any repeat doses within the authorized course, with its version or effective date. This field is what joins the individual decision to the practice's approved procedures. It does not do the opposite. A protocol describes what to do if a patient is a candidate; it never decides that this patient is one. The reference field exists so a reader can see which approved document the treating provider followed after the examiner made the decision.

Examiner signature

The examiner signs, dates and times the record. Not the front desk, not the injector on the examiner's behalf, and not the medical director at the end of the week unless the medical director is the examiner. A one-sentence attestation above the signature helps: for example, that the examiner personally evaluated the patient on the stated date by the stated modality and authorizes the treatment listed. In an EHR, the electronic signature and its audit trail serve this purpose, provided each user signs under their own credentials.

An illustrative layout

How to Fill It In at the Visit

The form works best when it follows the order of the visit rather than the order of a legal checklist. A sequence many practices use looks like this:

1. Before the examiner sees the patient, staff confirm identity and a current intake, and open a new record pre-populated only with identifiers. Nothing clinical is pre-filled.
2. The examiner opens the encounter under their own name, credential, modality and start time.
3. History, medications and allergies are reviewed with the patient and the relevant points recorded.
4. The examination follows, and findings are recorded as observed.
5. Contraindications are worked through against the protocol list for the requested service.
6. The examiner records the assessment and, if the patient is a candidate, the specific treatment authorized and the protocol reference.
7. The examiner signs. Only then does the record move to the consent step and the treating provider.

The point of the sequence is that the signature comes last and the treatment comes after it. A form signed at the start of the visit and completed afterwards, or completed by someone else and signed by the examiner later, records the steps in an order that did not happen.

Good Faith Exam vs Informed Consent: Why You Need Both

The good faith exam form and the informed consent form are often stapled together, signed in the same visit, and treated as one document. They are not, and a practice that merges them usually ends up with a record that does neither job well.

Different authors, different questions

The exam records a clinical judgement made by the practitioner; consent records an informed choice made by the patient once that judgement exists. A perfectly drafted consent signed by a patient who was never evaluated documents an agreement to a treatment nobody with authority ordered. A thorough exam with no consent documents a sound clinical decision the patient never agreed to. Each gap is serious on its own, and neither document can fill the other's.

Why both belong to the same visit

Keep the documents separate, but make the link between them obvious. The consent should name the treatment the exam authorized, and the exam record should note that consent was obtained for it, so a reader can see which evaluation the consent relates to. If the examiner authorizes a modified plan, the consent has to match the modified plan, not the original request. Our med spa consent forms guide covers what the consent document itself must contain for each service and links to procedure-specific templates.

The combined form trap

A single "exam and consent" page with only the patient's signature no longer shows that a practitioner made a decision; it reads as the patient approving their own treatment. If you combine them, give the exam portion its own examiner signature block, completed first.

How Often Is the Good Faith Exam Redone?

Our state-by-state good faith exam guide finds no covered state that publishes a numeric re-exam interval. The triggers it identifies are events rather than dates: every new patient; a new product, indication or treatment area added for an existing patient; and a material change in the patient, such as a new medication, pregnancy, a new diagnosis or an adverse reaction to an earlier treatment. Repeat doses within a course the examiner has already authorized may generally continue under the existing order in states that permit standing orders for that purpose.

Beyond those triggers, how often your practice re-evaluates continuing patients is set by your medical director's protocol. Write the policy down, and describe it as your practice's standard rather than as a rule your state imposes.

What the form needs to support re-examination

• A clear scope of authorization. Because the record lists exactly which treatments were authorized, a reader can tell immediately when a later treatment falls outside it and needed a new evaluation.
• A return-visit check. At each return, staff confirm the interval health update and the treatment requested against the most recent exam record. If anything has changed, or the request is outside what was authorized, the patient is routed back to an examiner.
• A new record, not an edited old one. Each evaluation gets its own dated record. Amending an earlier form to cover a new treatment destroys the evidence of when each decision was made.

Documenting a Telehealth Good Faith Exam

Whether a remote exam is permitted, and for which treatments, is a state question. Our by-state guide finds remote examination permitted in some form in most of the states it covers, genuinely unsettled for cosmetic injectables in a small number of them, and the standard of care unchanged whether the visit is in person or remote. Check the by-state verdicts before relying on a telehealth model, and see our guide to telehealth prescribing for med spas by state for the wider prescribing picture.

Where a remote exam is allowed, the record has to carry more, not less, because a reviewer cannot assume anyone was in the room. Add these items to the standard form:

• Modality and platform. Whether the encounter was live audio-video or another format, and the platform used. Your medical director's protocol should say which formats are acceptable for which services.
• Locations. Where the patient was and where the examiner was at the time of the encounter. The examiner needs a licence valid for the patient's location.
• Identity verification. How the patient's identity was confirmed at the start of the call.
• Who else was present. Any staff member on the patient's side of the call, by name and role. An on-site nurse who held the camera did not examine.
• What could be assessed remotely. A short note on the findings obtained and any limitation of the remote format that affected the assessment.
• Start and end time. The duration is part of the evidence that a real evaluation took place.

Vendor records

If an outside telehealth company supplies the examiner, their full record must reach your chart before anyone treats. A notification email that a patient was "cleared" is not a good faith exam record. Our guide to remote and telehealth medical director arrangements covers the oversight side of those models.

How the Form Connects to Standing Orders and the Chart

The good faith exam record is one link in a chain that runs from the medical director's protocols to the syringe. Each link answers a different question, and the chart only holds together if each one points to the next.

1. Protocol or standing order, signed by the medical director, describing how a service is delivered to patients who are candidates.
2. Intake, collected from the patient, supplying the history the examiner reviews.
3. Good faith exam record, in which the examiner decides this patient is a candidate and authorizes a specific treatment, referencing the protocol.
4. Informed consent, in which the patient agrees to the authorized treatment.
5. Treatment record, in which the administering provider documents what was actually done, by whom, and when, consistent with the authorization.

The protocol reference cuts one way

The standing-order reference on the exam form tells a reader which approved procedure governed the treatment. It does not mean the protocol authorized the treatment. A standing order describes a class of patients; the exam record decides that an individual belongs to it. A chart that contains a protocol and a treatment note but no exam record in between has skipped the decision. Our guide to med spa standing orders and protocols covers how those documents should be written and signed.

Medical director review is not the exam

Retrospective chart review by a medical director is valuable oversight. It does not create a good faith exam after the fact, and a countersignature added days later should never be presented as one. If your medical director reviews exam records, give the review its own dated signature line, separate from the examiner's, so the record shows two distinct acts.

Filing the Form: Where It Lives in the Record

A good faith exam that cannot be found is, for practical purposes, one that did not happen. Filing is not an afterthought.

• Keep it in the patient's medical record, not in a separate binder, a telehealth vendor's portal or a shared drive folder labelled "GFEs." It is clinical documentation and should sit with the rest of the chart.
• Use a consistent document type in your EHR so every exam record can be pulled by patient and date.
• Lock it once signed. Corrections should be made as dated, attributed addenda, not by overwriting. Electronic audit trails will show any change, and an altered timestamp is far more damaging than an honest late entry clearly marked as one.
• Archive blank versions. Keep a copy of each version of the template with the dates it was in use, so you can show what the form looked like at any point.
• Protect it like any other health record. The form contains protected health information, and access, transmission and storage follow your HIPAA program; our HIPAA compliance guide covers the essentials.

Common Audit Failures on Good Faith Exam Forms

These are the patterns that turn up when a reviewer pulls exam records. Most are document problems that a better form and a clear workflow fix.

No examiner identified

The form has a signature but no printed name or credential, or a credential line that was never completed. The reviewer cannot confirm the person was permitted to perform the exam, which is the first thing they need to know.

The wrong person in the examiner field

The form names an injector whose credential does not permit them to examine, or names a physician who was not involved while the actual assessment was done by someone else. Either way, the record documents a decision made by someone without authority, or misattributes it.

Identical findings across patients

Every record shows the same findings, the same "no contraindications" entry and the same approval. Uniformity reads as automation, and a reviewer will conclude the exam was a formality.

Signed after treatment

The examiner's signature time follows the treatment time, or the exam record was created after the treatment note. The record then shows the treatment preceded the decision that was supposed to authorize it.

Authorization too vague to act on

The treatment field says "neurotoxin" or "aesthetic services" with no area, product or bounds. The administering provider then made the real decisions, which is the problem the exam was supposed to solve.

Treatment outside the authorization

A patient authorized for one treatment receives another, or a new area, under the original record. The exam record is fine; the gap is that no new decision was made.

Intake standing in for the exam

The only clinical document is the patient's own questionnaire, sometimes with a practitioner's initials added. An intake form feeds the exam; it is not the exam.

A simple self-audit catches most of these: pull a handful of recent records at random each quarter, and for each one ask whether a stranger could identify who examined the patient, when, by what modality, what they found, what they authorized, and whether the treatment matched. Record what you found and fixed. Our med spa inspection guide covers what reviewers typically ask for and in what order.

How Long Should You Keep Good Faith Exam Records?

Keep the good faith exam record for as long as you keep the rest of the patient's medical record, because it is part of that record. Retention periods are set by state law and can be affected by other rules, such as those that apply to records of minors or to particular payers, so the period that applies to your practice is a question for your healthcare counsel. Never keep exam records for less time than treatment notes.

When a practice closes, sells or changes EHR vendors, exam records go with the rest of the chart and remain retrievable for the full retention period. Our medical records retention guide walks through how to build a retention schedule and what to do at closure or sale.

Key Takeaways

• The form records a prescriber's decision; it never replaces the examination.
• Give every element its own field, and never pre-fill findings or the assessment.
• Who may fill the examiner field, and whether telehealth is allowed, are state questions our by-state guide answers.
• Keep the exam record and informed consent separate, signed by different people, and clearly linked.
• File the record in the chart, lock it once signed, and have your medical director and counsel approve the template.

This page offers general information on structuring a good faith exam record. It is neither medical nor legal advice, sets no clinical standard and does not state any state's law; for state-level verdicts, see our good faith exam by state guide. Before the form goes into use, your medical director should approve it and healthcare counsel licensed in your state should review it.