Prescription Refill Request Form

Only for use by current active patients of Cornerstone Psychiatric Services

Once we receive your Prescription Refill request, we will do our best to send your refill to selected pharmacy by end of business day as long as your refill is due. Please do not call the office for this same rx refill request and avoid from calling the office multiple times for status of your refill request. We kindly ask that you check with your pharmacy on the status of your refill order.

Important Note: We only respond to this online rx refill request

Monday - Thursday: 8:00 a.m.-4:00 p.m. and Friday 8:00 a.m. - 11:00 a.m. *

*Except on holidays when the office is closed, we will respond the next business day we are open.

If you submit your request outside these hours or on a Saturday or Sunday, your request will be responded to the next business day.

This form is for Prescription Rx refill use only. DO NOT use this to communicate to our office or your clinician for any other purpose. This form is not for emergency use or emergency communication. If you have a life-threateninig emergency, please call 911 or go to your local emergency room. If you need to contact the office for something important, please call us at 941-488-8884.

Patient Name*

First NameLast Name

Account #:

What is your CPS account #? If not known, leave blank

Date of Birth*

Date

Patient Phone Number*

Select Prescribing Clinician?*

Prescription Refill request details*

	Medication Name	Dosage (in mg or other)	Directions (how to take)	30 day Quantity	√ 90 day supply
1
2
3
4
5
6
7

This refill is to go to?*

Local pharmacyMail order only pharmacy

What city is your pharmacy located?*

THIS SECTION IS NO LONGER USED: What do you want done with printed prescription?*

Pick up printed prescription at Cornerstone Psychiatric officeMail printed prescription to my home address (provide address in additional details below)Other

Bradenton Pharmacies:*

Englewood Pharmacies:*

Lakewood Ranch Pharmacies:*

If you don't find your pharmacy here, check under Bradenton, FL pharmacies

Nokomis Pharmacies:*

North Port Pharmacies:*

Osprey Pharmacies:*

Port Charlotte Pharmacies:*

Venice Pharmacies:*

Pharmacy*

Mail Order Pharmacies:*

Other Pharmacy name not listed:

Pharmacy Phone#:*

Pharmacy Address:

Street Address

Street Address Line 2

CityState

Pharmacy Fax#: (if known)

Area CodePhone Number

Additional Details you wish to provide us?

Provide Pharmacy contact details if not pre-selected above.

Please verify that you are not a robot*

Notice

Best method to request your prescription refills is contacting your pharmacy directly and have them send your prescribing provider an electronic (eprescribe) refill request. If this is done, then please do not call our office or send this online prescription refill request as you are only duplicating this process and taking time away from the front office staff from providing quality service for other purposes.
Before Submitting this request, please double check your prescription bottle to verify if you have any refills remaining. If you have refills remaining, then DO NOT USE this form and instead simply call your pharmacy for your refill.
Please do not ask us to call you back with status or confirmation of your refill request. Your request will be processed as quickly as possible and based on the refill date due. Please contact your pharmacy and speak to a live person instead of automated call system regarding your refill status.
This form is for Prescription Rx refill use only. DO NOT use this to communicate to our office or your clinician for any other purpose. This form is not for emergency use or emergency communication. If you have a life-threateninig emergency, please call 911 or go to your local emergency room. If you need to contact the office for something important, please call us at 941-488-8884.

Prescription Refill Request Form

Prescription Request Details