Template for refusing or withdrawing from a procedure
Not every patient accepts what the professional recommends, and not every scheduled procedure takes place. A patient may refuse a course of action you consider necessary, back out in the chair, or change their mind after paying. Respecting the decision is their right. Documenting it well is your responsibility.
The refusal form records, on one page, what you advised, what the patient decided and which risks they were warned about. The template below is generic and includes no technique, dose or brand.
When should you use this template?
In two main scenarios. Refusal of a clinical recommendation: the patient rejects a course of action the professional considers necessary, such as a follow-up visit, a test, a safety measure or treatment of a complication. Withdrawal: the patient had accepted the procedure and changes their mind before the injection. For refusal of a purely aesthetic procedure, the record can be brief. For refusal of something related to safety, the form should be more detailed.
How do you adapt it?
- Describe the recommendation or the course of action refused in language the patient understands, without jargon.
- Record the possible consequences of not going ahead, without exaggerating or threatening. The information must be honest and proportionate.
- Offer alternatives and leave the door open to resume.
- Record the reason, if the patient wants to share it, but do not demand a justification.
- Handle amounts already paid: if payment was made, what happens next should be set out in the contract or the clinic's policy. See the package contract template and the cancellation policy template.
- File it in the medical record with the date and give the patient a copy.
- Have a lawyer review the text and check your professional board's rules.
What must never be missing?
| Item | Reason |
|---|---|
| Identification of patient and professional | Who decided and who advised |
| Course of action or procedure refused | Makes clear what was refused |
| Advice given and risks of not going ahead | Proves the information |
| Alternatives offered | Shows there was dialogue |
| Free decision, without pressure | Respects autonomy |
| Possibility of resuming | Keeps the relationship |
| Date, place and signatures | Validity of the record |
Template for refusing or withdrawing from a procedure
What if the patient refuses to sign?
Do not push. Record in the medical record, with date and time, what was advised and that the patient refused to sign the form, preferably with the signature of a witness from your team. Keep a friendly tone and the door open: refusal does not end care. To handle dissatisfaction and conflict, read unhappy patient: how to handle it. For the documents that belong in the medical record, see medical records and documentation in HOF. When the refusal comes after a medical history that flagged a risk, record that connection too. Also recall the basis of all this in informed consent and protect the data in line with the LGPD.
Frequently asked questions
What is a treatment refusal form?
It is a document in which the patient states that they received the professional's advice about a recommended course of action, understood what may happen if they do not follow it, and decided to refuse. It records the information given and the patient's decision, but it does not replace the entry in the medical record.
The patient refused the procedure and wants to sign a form. Does it protect me?
It helps show that the patient was informed and decided on their own, but it does not automatically remove all liability. Also record in the medical record what was advised and the decision. Ask a lawyer to review the text.
What is the difference between refusal and withdrawal?
Refusal is when the patient does not accept a recommended or proposed course of action. Withdrawal is when they had accepted and change their mind, before or during the procedure. Both must be respected and recorded, and the patient may withdraw before it starts without having to give a reason.