Patient Registration

You may preregister with our office by filling out our secure online Patient Registration Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. On your first visit to our office, we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Online patient registration form

For more information or to schedule a consultation with Dr. Cusack, call our office in Peoria, IL at Peoria Office Location Phone Number 309-693-2220 or request an appointment online.