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Life Stone Counseling Centers offering Mental Health services in Utah: Midvale, American Fork, West Jordan and Virtual
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RX Refill Request for

Dr. Allison Cirenza

Please complete the form below fully and clearly. Missing information may delay processing. Please do not call the office to check the status of your request; we will respond as quickly as possible.

This refill request form is for current clients only and is intended for urgent situations, such as when you will run out of medication before your next scheduled psychiatric follow-up or when an emergency prevents you from attending a scheduled appointment. Medication refills are typically provided during regularly scheduled psychiatric follow-up visits.

Medication refills may not be authorized in the following situations:

  • You do not currently have a psychiatric follow-up visit scheduled with one of our psychiatric providers and/or one of our psychiatric providers for an extended period of time

  • You often cancel or miss scheduled appointments at our practice.

  • You have an outstanding balance for services received at our practice.


▶ The length of time needed to respond to your request will depend upon factors such as the office hours of your psychiatric provider and the day of the week you submit your request (we do not respond to requests on weekends or holidays). We will respond to your request as quickly as possible, but please be aware that typically it takes 3 business days before you receive a reply.
Full Client Name Client E-mail Client Date of Birth Name of Medication & Specific Dosage Pharmacy Name Pharmacy Address Pharmacy Phone Notes for Dr. Tonya Wright I agree to the Terms & Conditions and Privacy Policy Submit
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