Atlanta Area Family Psychiatry Clinic, P.C. (AAFPC) Prescription (Rx) by Email request page

Date of request:

Your name:

Click on arrow to scroll down to Select your physician:

Patient's name: *

Patient's DOB:

Medication #1----------------: *

Medication #1 Dose (mg): *

Medication #1 Directions: *

Medication #2----------------:

Medication #2 Dose (mg):

Medication #1 Quantity: *

Medication #1 Note:

Medication #2 Directions:

Medication #2 Quantity:

Medication #2 Note:

Last Appointment: *

Your phone numbers. Home: *

Last refill date----:

Office:

Cell:

FAX is our PREFERRED and the most efficient method to communicate requests to pharmacies.

Are any of these new numbers?

or phone to pharmacy, telephone:

or Mail to YOUR HOME or Business address (not pharmacy) below:.

Name:

Street 1:

Zip:

City:

State:

Street 2:

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Expedited handling (same day service $15 fee) :

Click to submit all information to AAFPC by E-Mail >

Atlanta Area Family Psychiatry Clinic, P.C. (AAFPC)

Email prescription refill request

Please allow FIVE FULL BUSINESS DAYS for completion of your request.

Also 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 are Mail or Pick-up only.

To send: press the "Submit" button at bottom of page.

Fill in all appropriate fields,

( * = required field )

Use "Tab" to go to next box or "Shift"+"Tab" to go back.

Pick up at AAFPC (M-Th 9 am - 5:00 pm; Fridays by NOON): No/Yes

Your E-Mail:

Enter your Pharmacy's FAX number :

If you are picking up a prescription, please call (770) 393-1880 ext 0 to verify that your prescription is ready.

Adderall, amphetamine salts, Concerta, Daytrana, Dexedrine, Dextrostat, Metadate, Methylin, methylphenadate, Ritalin, Vyvanse are Mail or Pick-up ONLY.

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

Atlanta Area Family Psychiatry Clinic, P.C.

Psychiatric and psychotherapeutic care for adults, children, adolescents and families

since 1977

PREFERRED