PATIENT Registration


Please arrive 15 minutes prior to your appointment time.

*Remember to bring your ID, current medical insurance card, your glasses and a list of current medications.

We look forward to seeing you at your up coming appointment.

If you would prefer to fill out the forms and print them out, the links are below. Please fax them to 512-868-3907 or email them to info@clarityeye.net prior to your appointment.

 

Demographic Information

Person NOT living with you.

Insurance Information

Please fill out information correctly and attach an image of the front and back of your insurance cards.
If self pay, type self pay.
If self pay, type self pay.
Drop your file here or click here to upload.
Drop your file here or click here to upload.
Drop your file here or click here to upload.
Drop your file here or click here to upload.

Payment Agreement

By initialing here, I agree that I have received and read the Clarity Eye Center Payment Agreement. Privacy & Payment Agreement Form (English) Formulario de Prividad y Acuerdo de Pago (Español)

Notice of Privacy Practices


Printable Registration Forms

 

Registration Form (English)

Formulario de Inscripcion (Español)

Privacy & Payment Agreement Form (English)

Formulario de Prividad y Acuerdo de Pago (Español)

Notice of Privacy Practices (English)

Notificación de prácticas de privacidad (Español)

Disclosure Authorization (English)

Divulgación a amigos, cuidadores y / o miembros de la familia (Español)

Copyright © 2019 Clarity Eye Center | <a href="https://www.clarityeye.net/wp-content/uploads/2017/11/notice-of-privacy-practices-copy-for-patient.pdf">Notice of Privacy Practices (English)</a> <a href="https://www.clarityeye.net/wp-content/uploads/2017/11/Notice-of-privacy-practice-Spanish-only.pdf">Notificación de prácticas de privacidad (Español)</a>