Good Faith Exam Form for Med Spa, Botox, IV Therapy, and Delegated Treatment

A Good Faith Exam form helps a medical practice document the intake, review, assessment, treatment plan, and provider order that may be required before a nurse or other delegated clinician performs services such as Botox, filler, IV therapy, laser treatments, weight-loss injections, or other medical aesthetic and wellness procedures.

EasyDocForms can support the form and documentation workflow. It does not decide whether a specific Good Faith Exam process is legally sufficient in your state, and it does not replace a physician, nurse practitioner, physician assistant, medical director, attorney, or licensing-board guidance.

What a Good Faith Exam Is

In medical spa and IV therapy settings, "Good Faith Exam" is commonly used to describe an initial medical evaluation performed before treatment. Depending on state law and the service involved, this evaluation may be called an appropriate prior examination, initial assessment, provider evaluation, consultation, or establishment of a provider-patient relationship.

The practical purpose is usually to:

• Review the patient's health history.
• Confirm the requested treatment is appropriate.
• Screen for contraindications.
• Establish or update the provider-patient relationship.
• Create a patient-specific treatment plan or order.
• Document the licensed provider responsible for the evaluation.
• Define what a delegated nurse or other clinician is authorized to perform.

Who Performs the Exam

Rules vary by state and license type. In many med spa and IV therapy workflows, the Good Faith Exam or equivalent provider evaluation must be performed by an authorized licensed practitioner such as a physician, nurse practitioner, or physician assistant. Registered nurses may collect intake information and assist with the workflow, but they generally should not independently diagnose, determine medical necessity, prescribe, or create treatment orders unless state law gives them that authority.

For example, California Medical Board guidance says physicians remain responsible for supervision when medical procedures are delegated, that the physician is responsible for examining the patient before delegating a task to an RN, and that an appropriate prior examination is required when prescriptive drugs or devices are used. California BRN guidance for Botox says there must be a Good Faith Examination before the prescription is provided and that Botox injection is the practice of medicine.

South Carolina boards issued IV hydration guidance warning that RN-only assessment and treatment-selection workflows can constitute the unlicensed practice of medicine when no authorized practitioner evaluates the patient and establishes the proper relationship before prescribed drugs are administered.

Does the Doctor Need to Be Physically Present?

This is state-specific. Some states allow certain delegated medical treatments when the supervising or ordering provider is not physically on site, if the provider has completed the required evaluation, issued an appropriate treatment order, maintains required supervision, is available as required, and the treatment location meets applicable medical-setting rules. Other states or services may require physical presence, on-site medical personnel, or stricter supervision.

EasyDocForms should be used to document the workflow your clinical and legal advisors approve. Do not use a Good Faith Exam form as a workaround for a missing medical director, inactive provider, unavailable supervisor, unsigned order, or state rule that requires in-person or on-site supervision.

What the Form Should Capture

A Good Faith Exam form can include patient-completed intake plus provider-completed review fields.

Section	Common fields
Patient identity	Patient demographics, DOB, contact information, preferred pharmacy, emergency contact.
Requested service	Botox, filler, IV hydration, vitamin infusion, GLP-1, laser, microneedling, chemical peel, or other service.
Medical history	Diagnoses, surgeries, prior procedures, prior adverse reactions, current symptoms, and treatment goals.
Medication history	Current prescriptions, OTC medications, supplements, anticoagulants, antibiotics, isotretinoin, GLP-1 medications, and relevant product use.
Allergies and contraindications	Medication allergies, latex allergy, lidocaine allergy, pregnancy, breastfeeding, neuromuscular disorders, immune concerns, infection, recent procedures, and service-specific exclusions.
Vitals or objective findings	Blood pressure, pulse, oxygen saturation, weight, relevant skin or treatment-area findings, and other findings required by protocol.
Provider assessment	Whether the patient is an appropriate candidate, risks reviewed, alternatives discussed, treatment area or infusion selected, and whether additional evaluation is needed.
Treatment order	Service authorized, dose or units when applicable, route, treatment area, product, additives, frequency, expiration or renewal date, and limits for delegated staff.
Delegation details	Authorized clinician type, required supervision level, escalation criteria, and when to stop or contact the provider.
Signatures	Patient acknowledgment, provider signature, clinician countersignature, witness signature when needed, and date/time metadata.

Example Workflows

Botox or Neurotoxin Good Faith Exam

A Botox Good Faith Exam form can collect the patient's medical history, medication list, allergies, neuromuscular history, pregnancy or breastfeeding screening, prior toxin reactions, treatment goals, target areas, provider assessment, and patient-specific order.

For delegated nurse injector workflows, the order should be specific enough for the clinician who will perform the treatment under the practice's state-specific rules and protocols.

IV Therapy Good Faith Exam

An IV therapy Good Faith Exam form can collect medical history, medication and supplement history, allergy history, pregnancy screening, symptoms, treatment goals, vitals, contraindications, selected infusion, additives, provider assessment, and treatment order.

For IV nurses using the iOS provider app, EasyDocForms can also support medication barcode scanning directly into the clinical note workflow, which helps document medication or product package details during the encounter.

Med Spa Treatment Good Faith Exam

For med spa services such as filler, laser, microneedling, chemical peels, body contouring, or wellness injections, the form should be specific to the treatment risk profile. A general "cleared for all services" order may not be detailed enough for delegated treatment, especially when different services involve different contraindications, products, devices, treatment areas, or escalation criteria.

Recommended EasyDocForms Setup

1. Create a Good Faith Exam intake form for the patient-facing history and screening questions.
2. Add service-specific conditional sections for Botox, filler, IV therapy, laser, GLP-1, or other services.
3. Add medication, allergy, contraindication, and pregnancy or breastfeeding screening fields where relevant.
4. Add provider-only fields for assessment, treatment plan, order, delegation instructions, and expiration or renewal date.
5. Add consent documents and signatures for patient acknowledgment and provider signature.
6. Use patient profiles and clinical documentation so completed forms, notes, and follow-up context stay connected.
7. Attach the form to scheduling visit types or Square Appointments services so the right exam packet is sent before the appointment.

Renewal and Change Triggers

Practices should define when a Good Faith Exam must be repeated or updated. Common triggers include:

• New patient.
• New treatment category.
• Material change in medical history.
• Medication change.
• Pregnancy, breastfeeding, surgery, infection, or adverse reaction.
• Long gap since the prior exam.
• Expired treatment order.
• State-specific annual or periodic review requirement.

What Not To Do

Avoid using the form to imply that:

• A registered nurse independently performed the Good Faith Exam when state law requires a physician, NP, or PA.
• A medical director "on paper" is enough without actual evaluation, supervision, and orders.
• A standing protocol alone replaces patient-specific assessment when patient-specific assessment is required.
• A telehealth review is valid in every state or for every treatment.
• One generic approval covers unrelated treatments indefinitely.
• The form itself authorizes treatment without the required licensed provider review.

Related EasyDocForms Pages

• Med Spa Intake and Consent Forms
• Nurse Injector Consent Forms
• IV Therapy Intake and Consent Forms
• Consent Documents and Signatures
• Clinical Documentation
• HIPAA Compliance and BAA

Regulatory Context

Good Faith Exam rules are state-specific. Review your state medical board, nursing board, pharmacy board, telehealth rules, medical director agreement, delegation documents, malpractice coverage, and attorney guidance before using live patient workflows.

Useful public references:

• Medical Board of California: The Business of Medicine - Medical Spas
• California Board of Registered Nursing: RNs Performing Botox Cosmetic Injections
• South Carolina Joint Advisory Opinion on IV Hydration
• New Mexico Medical Board: Medical Spa Practice FAQ
• American Med Spa Association: Good Faith Exams