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Reno Psychiatric Associates
New Patient Questionnaire
* Disclosure: Dr. Mechibelle Lynch is strictly Telemedicine. She is unable to prescribe controlled substances.*
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Name
*
Your answer
Age
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Date of Birth
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DD
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Race/Ethnicity
Your answer
Gender
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Female
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Email
*
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Phone Number
*
Your answer
Address
*
Your answer
Social Security Number
*
Your answer
Employer
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Occupation
Your answer
Insurance Information
Please email a copy/picture front and back of your insurance card to company email at info@renopsychiatric.com
Insurance
*
Your answer
Insurance Id
*
Your answer
Credit Card Number
*
Your answer
Credit Card Expiration Date
*
Your answer
Credit Card CVV
*
Your answer
Preferred Pharmacy
*
Your answer
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