New Patients
Instructions
The doctors of Blue Fish Pediatrics have decided to restrict the size of our practice to continue to provide the best quality of care for our patients. The information on this form will be used to that end. After filling out the application, return the form via email, fax, or mail. You will be notified when we are able to accommodate new patients. Please continue to see your current pediatrician until that time.
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Thank you for choosing Blue Fish Pediatrics. To register a new patient, please download and fill out all of the following forms. We ask you to have these forms completed, signed, and dated before you arrive so that your wait period is not longer than necessary.
You can download all of the forms at one time by clicking here:
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All New Patient Forms (MEMORIAL)
All New Patient Forms (CYPRESS)
Transfer of Medical Records Authorization (CLARKE)
Temporary Guardian Consent Form
On your first visit, please indicate the name and address of the local pharmacy you would like e-prescriptions sent on your sign in sheet. This program allows doctors to send in prescriptions electronically right here in the office. To assist in finding a local pharmacy, follow this link: Get Rx Connected
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You may also download each file individually. Below is a brief explanation of each form as well as a link to download the form.
Office Policy: This form explains Blue Fish’s policy regarding office visits.
New Patient Registration: This form records general and health insurance information about the patient.
Transfer of Medical Records Authorization (MEMORIAL)
*IF YOU ARE A CLARKE PATIENT, USE THIS FORM: Transfer of Medical Records Authorization (CLARKE)
Transfer of Medical Records Authorization (CYPRESS)
This form allows Blue Fish Pediatrics access to your previous medical records.
Patient Medical History Questionnaire (MEMORIAL): This form records the medical background of the patient and blood relatives.
Patient Medical History Questionnaire (CYPRESS)
Temporary Guardian Consent Form: This form gives consent to allow your child to come to the office with a temporary guardian (such as a grandmother or nanny).
TXDSHS Immunization Registry Consent Form
This form allows the State of Texas to have an electronic copy of your child’s immunization records. If you consent and you ever lose your child’s immunization records, TXDSHS can replace them for you. If you do not consent, please sign and date under the “WITHDRAWAL OF WRITTEN CONSENT” area. If you do consent, please sign and date above the “WITHDRAWAL OF WRITTEN CONSENT” area.
Texas Vaccines for Children Form (TVFC) Patient Eligibility Screening Record
This form determines whether your child is eligible for TVFC. If your child is qualified for TVFC, please sign and date.
Texas Vaccines for Children (TVFC) Program Information
This form is a disclaimer stating that your child is not qualified for TVFC and that the parent/guardian is responsible for all costs associated with vaccinations. If your child is not qualified for TVFC, please sign and date.
Health Insurance Portability and Accountability Act (HIPAA) Authorization
This form explains the privacy rights of the patient’s medical records.
If you are having problems filling out these forms, please contact our office at 713-467-1741. If it is after hours, please leave a message and a receptionist will contact you the following business day.