Prescription Request Print Out Page for FAX Rx Refill Request Form
Please allow FIVE FULL BUSINESS DAYS for completion of your request. 
Note that some mail-in programs take up to three weeks to fill your prescription. 
Adderall, amphetamine salts, Concerta, Daytrana, Dexedrine, Dextrostat, Metadate, Methylin, methylphenadate, Ritalin, Vyvanse and others are Mail or Pick-up only. 
Print this page, fill out appropriate sections and FAX to (770) 393-1885

Date of request: ______/_____/__________
Please check your doctor's name:

L. Ashley,M.D. __;      T. Iwanicki, M.D. __;          S. Kirsch, M.D. __;             S. Neely, M.D. __   
 L. Perez, M.D. __;       E. Slayden, M.D. __;          R. Slayden, M.D. __;          L. Waugh, M.D. __

Your name: _____________________________________________________________

Patient's name: _______________________________________________  Patient's DOB:___/___/_____

Med#1: __________________________________________________________ Dose(mg):____________

    Directions:_________________________________________________________________________
    Quantity: _____
    Note: _____________________________________________________________________________

Med#2: __________________________________________________________ Dose(mg):____________

   Directions:_________________________________________________________________________
    Quantity: _____
    Note: _____________________________________________________________________________

Last refill date: ______/_____/__________; Last appointment:  ______/_____/__________

Your phone numbers; h:(____)_____-_________ 
                                      o:(____)_____-_________
                                      c:(____)_____-_________
                                                                                         Are any of these new numbers?  Yes _; No _
Pick-up? Yes __; No __  If you are picking up a prescription please call (770) 393-1880 ext 0,(M-Th F 9 am - 5:00 pm; Fridays by 12 noon) to verify that your prescription is ready . 

FAX to Pharmacy (____) _____-_________ ; (FAX is our PREFERRED method to                                        communicate requests to pharmacies except controlled medications)
or Call to Pharmacy (____) _____-_________
or Mail to:
Name _________________________________________________________________________________

Street ________________________________________________________________________________

City ______________________________________, State ____ ZIP____________ 
Is this a new address? Yes _; No _ 
Expedited handling (same day response, $25 fee. M-Th to 5 pm & Fr to noon) Print yes to confirm ____

Atlanta Area Family Psychiatry Clinic, P.C.
7000 Peachtree Dunwoody Rd, Building 16 Suite 100 ~ Sandy Springs, GA 30328
Telephone (770) 393-1880 ~ Facsimile (770) 393-1885
©  R. Slayden, M.D.
Atlanta Area Family Psychiatry Clinic, P.C.
Psychiatric and psychotherapeutic care for adults, children, adolescents and families 
since 1977