Ross A. Cusic O.D.
12911 120th Ave. NE
G105
Kirkland, WA. 98034
425/823-2020

Online Patient Form

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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Patient Information

Title	First	Last	MI	Suffix	Nickname

Address:

City:	State:	Zip Code:

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status		Employer / School Name
Misc/Guardian

Guarantor is the Person Responsible for the Bill;
If its NOT the patient registered above.

Only check this box if you are registering a Minor or Guarantor
Is The Billing Address the Same? Yes

Title	First	Last	MI	Suffix

Address:

City:	State:	Zip Code:
Home Phone:
Work Phone:

Primary Vision Insurance

Please have a hard copy of your major medical card present at your appointment.

Insurance Name:
Insurance Plan:
Insurance ID:

PLEASE USE ALL CAPITOL LETTERS. NO SPACES OR DASHES

Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	LAST name, FIRST name
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Vision Insurance

Please have a hard copy of your major medical card present at your appointment.

Insurance Name:
Insurance Plan:
Insurance ID:

PLEASE USE ALL CAPITOL LETTERS. NO SPACES OR DASHES

Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	LAST name, FIRST name
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Primary Medical Insurance

Please have a hard copy of your major medical card present at your appointment.

Insurance Name:
Insurance Plan:
Insurance ID:

PLEASE USE ALL CAPITOL LETTERS. NO SPACES OR DASHES

Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	LAST name, FIRST name
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Medical Insurance

Please have a hard copy of your major medical card present at your appointment.

Insurance Name:
Insurance Plan:
Insurance ID:

PLEASE USE ALL CAPITOL LETTERS. NO SPACES OR DASHES

Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	LAST name, FIRST name
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Submit Form

Ross A. Cusic O.D.
Optical Images
425/823-2020
opticalimages2@yahoo.com

Online Patient Form

Patient Information

Guarantor is the Person Responsible for the Bill; If its NOT the patient registered above.

Primary Vision Insurance

Secondary Vision Insurance

Primary Medical Insurance

Secondary Medical Insurance

Submit Form

Guarantor is the Person Responsible for the Bill;
If its NOT the patient registered above.