Good Faith Exams · Clinic account

Testing Exams

Every exam under this clinic's account for the past 18 months. Reports are emailed on signing and stay here to download for each client's file. Approvals are valid 12 months; records archive at 18.

Full Name *

Email *

Phone *

Good Faith Exams · Clinic side

Start the exam. Then hand over the device.

Your clinic completes this page and pays. The patient answers their own medical questions next privately.

Clinic name *

Patient full name *

Patient date of birth *

State of treatment *

Good Faith Exam · Your part

Your medical screening.

A licensed provider reads every answer before your video exam. Every row needs an answer "None" is one tap, but say it, don't skip it. Withholding information raises your risk of complications.

Height *

Weight *

Primary care provider *

Practice name?

I don't have one

All prescriptions, OTC & supplements *

Allergy details *

Any reaction or complication from a past treatment *

Safety & serious history select any that apply *

Pregnant, trying to become pregnant, or breastfeeding

History of vascular occlusion from an injectable

History of granulomas or nodules after filler

Cold sores (herpes) matters before lip or laser treatments

I have fainted during a medical or cosmetic procedure

Allergic reaction that required emergency treatment

Complication from anesthesia

A provider has told me not to receive cosmetic injections

None of these apply to me

Patient acknowledgment & informed consent. This examination determines whether I am medically appropriate for the requested treatment. I answered all questions truthfully and completely, and I understand withholding information may increase my risk. No treatment is risk-free and results cannot be guaranteed. The risks, benefits, alternatives, expected outcomes, and warning signs requiring immediate medical attention will be discussed in my video exam, where I may ask questions. Additional evaluation or testing may be required; I may be declined if treatment is not medically appropriate; and I may withdraw consent at any time before treatment. I understand this exam is conducted by telemedicine, which has limitations versus in-person examination, and I consent to it.

By checking this box, I consent to receive automated promotional and transactional text messages from Neu Eu Medical PLLC at the phone number provided. Consent is not a condition of purchase. Message and data rates may apply. Text STOP to cancel at any time.

I consent to receive care by asynchronous telehealth, understand its limitations versus in-person care, that I may be redirected to a live or in-person visit, and that no prescription is guaranteed. Emergencies: call 911

You’re Almost There Just One Last Step!
Please submit your details by clicking the Submit button below. Once you submit your information, our team will review your details and get in touch with you shortly.

You’re Almost There Just One Last Step! Please submit your details by clicking the Submit button below. Once you submit your information, our team will review your details and get in touch with you shortly.

You’re Almost There Just One Last Step!
Please submit your details by clicking the Submit button below. Once you submit your information, our team will review your details and get in touch with you shortly.