Contraindication Acknowledgment Statement Template
Many complications start with information the patient had and did not share: a pregnancy not yet announced, a medication they did not think was important, a previous reaction to a product. The contraindication acknowledgment statement is a simple record that reinforces the medical history conversation and makes clear that the patient was asked about the main points.
This template is a signed checklist. For the full list of situations, see general contraindications in facial harmonization.
What conditions usually go on the list
| Group | Example items |
|---|---|
| Pregnancy and breastfeeding | Pregnant, trying to conceive, breastfeeding |
| Allergies | To injectable products, anesthetics, latex or preservatives |
| Infections | Active on the skin, in the mouth or at the site, recent cold sore |
| Diseases | Autoimmune, neuromuscular, clotting disorders |
| Medications | Anticoagulants, antiplatelets, immunosuppressants, isotretinoin |
| Previous procedures | Permanent filler or filler of unknown origin in the area |
| Healing | History of keloids or poor healing |
Statement template
What to do when there is a positive answer
A Yes answer does not automatically mean refusal. Some conditions call only for caution or postponement; others require a conversation with the treating physician. Proceed like this:
- Clarify the item with the patient and record the details.
- Decide, on clinical grounds, whether the procedure goes ahead, is postponed or is declined.
- Record the decision and the reason in the patient chart.
- If you decline, consider the procedure refusal form when the patient insists.
Points of care
Plain language. Avoid terms the patient does not understand. "Anticoagulant" can be explained as "a medicine that thins the blood".
Update at every session. An old statement does not apply to a new procedure. Redo it or confirm verbally, with a record, at each session.
Readiness for complications. Having an up-to-date statement does not replace preparation: keep hyaluronidase and the emergency kit available when using hyaluronic acid.
Sensitive data. The document contains health information. Store it with restricted access, in line with the LGPD (Brazil's data protection law).
Fit with the other documents
The statement works well alongside the allergy and medication form, the informed consent and the medical history. Each has a role: one collects the history, another confirms what was said and another records the patient's informed decision. Used together and genuinely discussed, they reduce surprises and strengthen the relationship of trust.
Frequently asked questions
Does the contraindication statement replace the medical history?
No. The medical history is the clinical interview conducted by the professional. The statement is an additional record in which the patient confirms they have reported the conditions that may contraindicate or change the procedure.
Can the patient sign without reading?
They should not. The professional should go through the checklist with the patient, clarify terms and record questions. A signature without reading weakens the value of the document.
What if the patient checks a contraindication?
Stop the planning, assess the case, postpone or decline the procedure according to clinical judgment and record the decision in the patient chart. Some conditions require clearance from another professional.
Does the statement protect the professional from liability?
It helps document what was disclosed, but it does not remove the professional's responsibility for the clinical assessment. Have your attorney validate the text, and check your professional board's rules.