New Patient Application

Thank you for your interest in becoming a patient of Blue Fish Pediatrics.

If you would like to join us as a new patient, please fill out the application below. Once we have received your application, we will notify you if you have been accepted. Please note that due to their current practice size, some of our doctors have restrictions on new patients. If you have any questions, please call our office.

For Newborns: If your child is a newborn and you need to schedule an initial follow-up visit, please submit the application below and then call your chosen office so that we can expedite your application.

General Information
Mother's Name*
First Last
Mother's Date of Birth*
MM slash DD slash YYYY
Are you a first-time parent?*
- Yes
- No
Patient(s)*
First Name Last Name Gender Patient's Date of Birth / Due Date

Click the (+) icon to the right for additional patients (up to 5 total).
Phone*
Email*
Primary Insurance Information
Policyholder's Name*
Policyholder's Date of Birth*
MM slash DD slash YYYY
Insurance Plan Name*
Group No.
Member ID / Subscriber No.*
Confirm Member ID / Subscriber No.*
Do you have secondary insurance?*
- Yes
- No
Secondary Insurance Information
Please only use this section if you have secondary insurance. If not, please choose your preferred location and physician.
Policyholder's Name
Policyholder's Date of Birth
MM slash DD slash YYYY
Insurance Plan Name
Group No.
Member ID / Subscriber No.*
Confirm Member ID / Subscriber No.*
Location Information
Note: Dr. Katherine Lusk is now at our Fairfield location. Dr. Jessica Malek is now at our Memorial location.
Blue Fish Pediatrics Location*
Preferred Woodlands Location Physician*
2nd and 3rd Preferred Physician (recommended to expedite application process)
Preferred Cypress Location Physician*
2nd and 3rd Cypress Preferred Physician
Preferred Memorial Location Physician*
2nd and 3rd Memorial Preferred Physician
Preferred Katy Location Physician*
2nd and 3rd Katy Preferred Physician
Preferred Fairfield Location Physician*
2nd and 3rd Fairfield Preferred Physician
Preferred Greater Heights Location Physician*
2nd and 3rd Greater Heights Preferred Physician
Preferred Sugar Land Location Physician*
2nd and 3rd Sugar Land Preferred Physician
Preferred Sienna Location Physician*
2nd and 3rd Sienna Preferred Physician
Do you plan on following the standard American Academy of Pediatrics immunization schedule, which Blue Fish requires?***
- Yes
- No
Additional Information
Are any other family members existing patients of Blue Fish Pediatrics?*
- Yes
- No
List*
First Name Last Name Relationship

Click the (+) icon to include up to 3 family members.
How did you hear about Blue Fish?*
CAPTCHA

* Required
**The American Academy of Pediatrics / CDC immunization schedule can be found here.

First Name	Last Name	Gender	Patient's Date of Birth / Due Date

First Name	Last Name	Relationship

New Patient Application

General Information

Primary Insurance Information

Secondary Insurance Information

Location Information

Additional Information