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 [email protected]t

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

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

Expedited handling (same day response, $25 fee. M-Th to 5 pm & Fr to noon)
Print yes to confirm ____

Fax to (770) 393-1885 or email a copy to [email protected] 


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