Guide · Medical oversight
Good faith exam form: what the record should include
A good faith exam form is the clinician's record of the evaluation: who examined the client, how, what history and contraindications they reviewed, which treatments they approved or declined, and any limits. The form documents the exam; it is not the exam, and a form filled in without a clinician's evaluation does not meet the requirement.
This checklist covers what a complete record usually captures, so you can judge a template or a provider's paperwork. Your state's rules and your clinicians decide the final content.
Updated October 29, 2026. General information, not legal advice; rules differ by state.
Who, when and how
The client's identity and date of birth; the date and time of the exam; how it was conducted (in person, or by live video or audio where the state allows); and the examining clinician's name, credentials and the state license they practiced under, which must match the state where the client is treated.
The history the clinician reviewed
Medical conditions; current medications and supplements, including blood thinners; allergies, including to anesthetics or product ingredients; pregnancy, breastfeeding or plans to conceive; previous aesthetic treatments and any complications; and anything in the history that changes the risk of the treatment planned.
Treatment-specific screening
Each treatment has its own questions, and the record should show they were asked. For neurotoxins, clinicians commonly screen for neuromuscular disorders, infection at the injection site and pregnancy. For fillers, bleeding risk, active infection or inflammation, and prior filler or implant history. For lasers, peels and other energy treatments, recent isotretinoin use, photosensitizing medications, skin type and history of scarring.
These are examples, not a protocol. The clinician decides what a given client needs, and treatment protocols should come from your medical oversight.
The decision and its limits
The outcome: cleared, not cleared, or needs more information. The specific treatments and areas approved, any limits such as products, units, frequency or conditions to follow, and when the client needs a new exam, for example after a change in health or medications or before starting a different kind of treatment.
A record should allow "no". If every form a provider returns says cleared, ask how they decide.
Consent, signature and storage
Confirmation that the client consented to the exam (and to telehealth, if used), the clinician's signature, and where the record is kept. The form contains health information, so store it with the client's medical record, restrict access to staff who need it, and keep it for as long as your state requires for medical records.
Common questions
- Is there a standard good faith exam form?
- No single form is required nationally. Practices and good faith exam providers use their own, and some states specify what the documentation must contain. What matters is that a licensed clinician actually performed the evaluation and recorded it.
- Can my staff fill in the form for the clinician?
- Staff can collect the client's history in advance, but the evaluation, the decision and the signature belong to the licensed clinician who performed the exam.
- How long should I keep good faith exam records?
- Treat them as medical records and keep them for as long as your state requires those to be kept. Retention periods vary by state.
- Does a telehealth good faith exam need a different form?
- The content is the same; the record should also note that the exam was conducted by telehealth and how, for example live video, along with the client's consent to telehealth.
Good faith exams from KiteMD
KiteMD is piloting telehealth good faith exams for med spas: licensed clinicians, a flat fee per exam, and clinicians paid the same whatever the outcome.