John W. Bass, M.D. Plastic Surgery
(602) 485-1010
Toggle navigation
Home
State of the Practice
Consultation
Dr. Bass
Procedures
Procedures
Breast
Breast
Enlargement
Lift
Reduction
Implant Exchange
Implant Removal
Face
Face
Eyes
Brow-Forehead
Lasers
Hairline Lowering
Facial Implants
Nose
Lip Lift
Face Lifts
Body
Body
Liposuction
Tummy Tuck / Corsetplasty
Arm Lift
Buttock / Thigh Lift
Non-Surgical
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
Gallery
Gallery
Breast
Breast
Breast Augmentation
Breast Lift
Breast Reduction
Breast Implant Exchange
Breast Implant Removal
Face
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
Skin Depigmentation
For Men
For Men
Chin / Jawline
Face
Body
Forms
Forms
New Patient Registration Form
New Patient Health Form
Patient Intake Questionnaire
Updated Health Form
Contact
More
Back
Updated Health Form
Home
Updated Health Form
Patient Information
Name
*
First
Last
Phone
*
Email
*
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Health Information as of
*
Any restrictions for contacting you?
*
- Select -
No
Yes
Contact Restrictions
*
Your Age?
*
Date of Birth
*
Sex
*
- Select -
Female
Male
Other
Updated Health Information
Any new allergies to drugs?
*
If yes, what drug and describe symptoms?
Any new non-drug allergies (food, environmental, etc..)
Please list any surgeries since last visit
*
Date of last physical?
*
List all medications that you are now taking (including dose, frequency and reason for medication)
*
Please list any new diagnoses since last visit
*
I understand that the information I am submitting it to be true and accurate.
Patient Acknowledgement
*
Acknowledgement Date
*
Request a Consultation