Please Include Pharmacy Name, Address, and Phone Number (If not applicable please enter "N/A") *

Patient Date of Birth *

Medication Name *

Medication Dosage *

Please Select One:

Pharmacy

Pick up (Friday after 12pm)

Mail

Phone: 706-548-8697
Fax: 706-548-8698

A fee of $20.00 will be charged to the patient for medication refills required because of missed or rescheduled appointments and early refill requests.

Please be sure to speak with a member of the pharmacy's staff, the online RX systems are not always accurate.

Patients must have a follow-up appointment to receive a refill. If a patient has not seen Dr. Prowell in 6 months, a prescription refill will not be written until the next scheduled appointment.

Patient Name: *

I take one of the following medications (Vyvanse, Methylphenidate, Adderal, Concerta, Jornay, or Focaline) and I selected above that I would like it either mailed or that I will pick it up. *

Yes

Refill Requests

Date of Next Appointment *

Refill Requests

If you take more than one medication, please fill out one form for each.