RxRefills

Please see the following rules before completing this form:

You must first contact our office at (941) 488-8884 to receive your Patient Account Code.
This form can only be used by current patients of Cornerstone Psychiatric Services, Inc.
Prescription requests will only be filled during normal business hours.
This is a request and not a guarantee your prescription will be called in by the doctor or clinician. Contact your pharmacy to verify your prescription is ready for pick up before calling our office.

Note: Prescriptions for Adderall, Concerta, Ritalin LA, Focalin, Dexedrine, and other stimulants cannot be called in to your pharmacy. You must call the office to request these types of prescriptions and you will need to pick up your prescription at our office.

Patient Account Code

Date of Birth

Who is your doctor/clinician?
Dr Donahue David Fawks, ARNP
Presciription Name

Dosage (mg
(example: 10mg)
Quantity

Select the pharmacy you would like your prescription called to:
Other Pharmacy Name and Phone Number (if not listed above)

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