AAFPC, P.C. Prescription (Rx) by FAX request form

Prescription Request Print Out Page for FAX or email Rx Refill Request Form

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

Note that some mail-in programs take up to two weeks to fill your prescription.

Adderall, amphetamine salts, Concerta, Daytrana, Dexedrine, Dextrostat, Metadate, Methylin, methylphenadate, Ritalin, Vyvanse and others are Mail or ePrescribe only.

Print this page, fill out appropriate sections and FAX to (770) 393-1885 or email to Rx@AAFPC.net

Date of request: ______/_____/__________

Please check your doctor's name:

L. Ashley,M.D. __; T. Iwanicki, M.D. __; S. Kirsch, M.D. __; A. Nitsche, M.D. __

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; cell: (____)_____-_________

work: (____)_____-_________

home:(____)_____-_________

Are any of these new numbers? Yes _; No _

FAX to Pharmacy (except stimulant medications) (____) _____-_________

ePrescribe or FAX (except stimulant medications) are the PREFERRED method to communicate requests to pharmacies.

Pharmacy telephone number is REQUIRED for ePrescribe.

Pharmacy Telephone: (____) _____-_________

or Mail to:

Name _________________________________________________________________________________

Street ________________________________________________________________________________

City ______________________________________, State ____ ZIP____________

Is this a new address? Yes _; No _

Refill fee $25 for ALL Rx's filled outside of appointment

Expedited refill fee (same day response, $45 fee. M-Th to 5 pm & Fr to noon)

Print yes to confirm ____

Fax to (770) 393-1885 or email a copy to Rx@aafpc.net

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