John W. Bass, M.D. Plastic Surgery
(602) 485-1010
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Procedures
Breast
Breast
Enlargement
Lift
Reduction
Implant Exchange
Implant Removal
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Eyes
Brow-Forehead
Lasers
Hairline Lowering
Facial Implants
Nose
Lip Lift
Face Lifts
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Body
Liposuction
Tummy Tuck / Corsetplasty
Arm Lift
Buttock / Thigh Lift
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Non-Surgical
Cosmetic InjectablesÂ
Skin Depigmentation
Facial Sculpting / Dermal Fillers
Laser Skin Tightening / Resurfacing
Skin Restoration Products
For Men
For Men
Necklift
Facial Implants
Chin / Jawline
Body Sculpting
Non-Surgical
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Breast
Breast Augmentation
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Face
Browlift
Cheek & Chin
Eye Lid Lift
Lip Lift
Face Lifts
Hairline Lowering
Rhinoplasty
Body
Body
Corsetplasty
Liposuction
Tummy Tuck
Thigh/Buttock Lift
Upper Arm Lift
Non-Surgical
Non-Surgical
Botox
Laser Resurfacing
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For Men
For Men
Chin / Jawline
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Patient Information
Name
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Last
Age
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Height
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Weight
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Current Physician(s)
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Health Information as of
Health History
Previous Surgeries and approximate dates
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Medical Conditions of you or family members
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Do you smoke?
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Yes
If yes, packs per day?
How long have you been smoking?
Do you drink alcohol?
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No
Yes
If yes, how much?
How often?
Do you have problems with scarring?
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No
Yes
If yes, describe
Do you have bleeding or bruising problems?
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No
Yes
If yes, describe
Do you have any history of problems with anesthesia?
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No
Yes
If yes, describe
Regular medications and reason for taking
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List ALL drug and/or latex allergies
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The above information is accurate and complete to the best of my knowledge.
Acknowledgement Signature
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Acknowledgement Date
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