Compliance Tools
 Medical
Adherence Letter
Dear Patient,
Your medications will not work if you do not take them!!!
Your pharmacy has identified that you have not renewed your medications.
These medications were given to you to control your symptoms and to improve
your prognosis. Medications for the treatment of high blood pressure,
diabetes, high cholesterol, congestive heart failure and after a heart
attack are to be taken forever unless side effects occur or you are instructed
by your doctor to stop them. I would like to know why you have stopped
taking your medication. Please complete this form and return it to me
by mail or fax.
Dear Dr. _____________________ Date:_________________
I have stopped the following medications:
1. ___________________________________________________________________________
2. ___________________________________________________________________________
3. ___________________________________________________________________________
4. ___________________________________________________________________________
The reason for my doing so is that:
_ I don't believe the medication was effective.
_ I didn't understand that I was to continue the medication.
_ I was instructed to do so by my family doctor.
_ The medication was too expensive.
_ I was having the following side effects:
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
4. ________________________________________________________________________
I __would/ __ would not like a follow-up appointment to discuss my medications.
Name: _______________________________ Signature:___________________________
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