New Patient Registration FGorm 2022 - John W. Bass Plastic Surgeon

JOHN W. BASS, M.D., LTD.
(602) 485-1010
Health Information as of *

(Please Print Legibly & Fill In or Correct All Fields)
Patient’s Name *
Address (Street & Apt )
City
State
Zip
Home Phone
Cell Phone
Other Phone
Any restrictions for contacting you?
No Yes
E-mail
Contact Restrictions:
Age
Date of Birth
SEX
Female Male
Patient’s Employer
Occupation
Work Phone
Ext:
Is it okay to call you at work?
Yes No
Address (Street & Apt )
City
State
Zip
Emergency Contact
Relationship to Patient
How did you hear about Dr. Bass ?
City
Doctor
Nurse
Web Site
Seminar
Salon
Areas of Interest :
Facial Procedures:
Breast Procedures:
Body Procedures:
I understand that office visit charges are payable on the day service is rendered. I authorize Dr. Bass to bill my insurance company. Regardless of insurance coverage, I am responsible for all bills being paid in a timely manner. I understand that my contract is between Dr. Bass and myself.
Signature *
Date *

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