Medication Reconciliation Template for Telehealth Visits
Patient Information
Name
Date of Birth
Visit Date
Provider
Current Medications
Medication Name
Dosage
Frequency
Route
Indication
Allergies
Drug/Other Allergies
Over-the-Counter & Supplements
List (if any)
Medication Changes
List any new, discontinued, or changed medications
Adherence & Concerns
Medication adherence issues or concerns
Provider Notes