Patient Good Faith Exam

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Patient Name

Date of Birth

Address

Phone

Treatment Requested

Are you currently under the care of a physician?

Yes No

If yes, for what

Do you have or previously have a history with any of the following? (Check yes or no):

Diabetes

Yes No

Hepatitis

Yes No

HIV

Yes No

Abnormal Bleeding

Yes No

Anemia

Yes No

Thyroid problems

Yes No

Bleeding Disorders

Yes No

Blood Clots

Yes No

Seizures

Yes No

Heart Disease or Condition

Yes No

Active Skin Disease

Yes No

Autoimmune Disorder

Yes No

Cancer

Yes No

Accutane or acne treatment

Yes No

Chemotherapy / Radiation

Yes No

Eczema, rosacea, dermatitis or alopecia

Yes No

Glaucoma or other eye disease

Yes No

History of skin sensitivity

Yes No

Keloids or thick scars

Yes No

Hyperpigmentation

Yes No

Hypopigmentation

Yes No

History of cold sores / oral herpes

Yes No

Other medical condition

Yes No

Other medical condition name

If you answered yes to any medical-history item, please describe:

Have you had any of the following within the past 4 weeks?

Botox within the past 4 weeks

Yes No

Dermal fillers within the past 4 weeks

Yes No

Forehead / Brow Lift within the past 4 weeks

Yes No

Face Lift within the past 4 weeks

Yes No

Chemical Peel within the past 4 weeks

Yes No

Tanning booth / salon within the past 4 weeks

Yes No

Cosmetic surgery / procedure within the past 4 weeks

Yes No

If you answered yes to any recent procedure, please decribe:

Are you currently taking (or have you taken within the last 6 months) any of the following medications or topical products?

Retin-A

Yes No

Glycolic Acid

Yes No

Alpha Hydroxyl

Yes No

Isotretinoin / Accutane

Yes No

Aspirin

Yes No

Blood thinners

Yes No

If you answered Yes to any medication/topical item, please explain

Please list all medications (prescription, over the counter, vitamins, herbs, topicals, and supplements) you are currently using:

Please list any allergies you have to medication, materials, food, or metals:

Please list any prior surgeries you have had and the date the procedure was performed:

Are you currently pregnant or breastfeeding?

Yes No

Do you use nicotine products (smoking, vaping, patches, etc.)?

Yes No

Have you had alcohol in the last 24 hours?

Yes No

Please describe any other health history or concerns that you have that have not been addressed above:

Patient Digital Signature (Type Full Name)

Consent To Digital Signature:

I consent to signing this Good Faith Form electronically by typing my name in the signature box above.

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concierge@vraitouchemed.com
706-750-9475

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