When a Client Refuses to Sign: Documentation Protects Everyone
Dr. Geoff Carullo, DVM, FPCCP, DPCVSCA
- Articles
- 4 min read
One question I receive surprisingly often from fellow veterinarians is:
“Doc, what if the client refuses to sign our Declining Treatment Form? Wala na ba kaming protection?”
The short answer is no.
A client’s refusal to sign does not erase the fact that the veterinarian fulfilled the duty to explain the patient’s condition, recommended treatment, associated risks, and possible consequences of refusing medical advice.
What changes is how the event should be documented.
Some clients mistakenly believe that by refusing to sign a form, there will be no record of what happened.
That is incorrect.
If a client refuses to acknowledge the discussion in writing, the veterinary clinic should immediately create its own contemporaneous record.
One practical method is an Affidavit of Refusal to Sign, executed by the attending veterinarian or clinic employee, describing exactly what transpired.
The affidavit should state that:
This creates a written record that the discussion actually occurred.
Whenever possible, the refusal should be witnessed.
Ideally:
Independent witnesses generally carry greater evidentiary value because they have no employment relationship with the clinic.
Aside from the affidavit, the veterinarian should also document the encounter in the patient’s medical record.
Include details such as:
Medical records created at the time of the consultation are often among the most important pieces of evidence if questions arise later.
Some people become offended when asked to sign informed consent or declining treatment forms.
In reality, these documents exist to protect both parties.
They help demonstrate that the client received sufficient information to make an informed decision, while also protecting veterinarians from later claims that risks were never explained.
Good documentation does not replace good medicine.
It complements it.
No form can replace a respectful conversation.
Clients are far more likely to cooperate when they understand that the document is not a waiver of negligence, but simply an acknowledgment that the veterinarian has explained the available options, potential risks, and possible outcomes.
If a client still refuses to sign, remain calm.
Because in veterinary practice, what is properly documented today may become your strongest evidence tomorrow.
Dr. Geoff Carullo is a Fellow and the current President of the Philippine College of Canine Practitioners.
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