Patient Requesting Medication Refills

YOU MUST ANSWER EVERY QUESTION BEFORE HITTING THE SUBMIT BUTTON. IF YOU DO NOT, THEN THE INFORMATION WILL NOT BE SENT TO OUR OFFICE. ALSO, PLEASE REPEAT THE PROCESS FOR EACH ADDITIONAL PERSON REQUIRING REFILLS OR DOCUMENTATION:

Patient Info

First Name *

Last Name *

Date of Birth *

Name of Psychiatrist *

Date of Last Visit *

Name of Pharmacy *

Address of Pharmacy *

Phone Number of Pharmacy *

Order Refills fo up to 5 Medications

Medication Name
(Example) Concerta
(Example) Adderal

Dosage
36mg
5mg

Times Taken a Day
2x a day
1x a day

Prescription Refill #1

Name of Medication *

Dosage *

Times Taken a Day *

Prescription Refill #2

Name of Medication

Dosage

Times Taken a Day

Prescription Refill #3

Name of Medication

Dosage

Times Taken a Day

Prescription Refill #4

Name of Medication

Dosage

Times Taken a Day

Prescription Refill #5

Name of Medication

Dosage

Times Taken a Day

Note: Medication refills WILL NOT be given to an active patient, your request may take up to 72 hours to be granted

Founding Providers

Keisha Brown MD, FAPA
Jenelle Martin MD
Child, Adolescent and Adult Psychiatrists

Board Certified

3469 Lawrenceville Highway
Suite 103
Tucker, GA 30084
Phone: 770-939-6480
Fax: 770-638-1961

www.wellmedatlanta.com

Areas of Focus

ADD/ADHD
Anxiety
Depression
Women's Health
Social Skills Development
Panic Disorders
Group Therapy
Obsessive Compulsive Disorder
Bipolar Disorder
Asperger's Disorder
Eating Disorders
Self-Esteem Issues
Traumatic Events
Parenting Questions
Family Therapy
Schizophrenia
Alcohol and Drug Use in Teenagers
Child & Adolescent Psychotic Disorders
PTSD

3469 Lawrenceville Highway, Suite 103
Tucker, GA 30084

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Office Information

Monday - Friday 9AM - 5PM
P - (770) 939-6480
F - (770) 638-1961
W - www.wellmedatlanta.com