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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 Employment Status
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?
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:
Sex:
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:
Sex:
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:
Sex:
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:
Sex:
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