John W. Bass, M.D. Plastic Surgery

New Patient Registration Form

  • Patient Information

  • Employment Information

  • Emergency Contact Information

  • Area(s) of Interest

  • 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.

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