Forms

Below is a brief explanation of each form/document as well as a link to download the PDF.

• New Patient Registration: This form records general and health insurance information about the patient.
• Patient Medical History Questionnaire:This form records the medical background of the patient and blood relatives.
• 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 (ImmTrac) 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.
• 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) Disclaimer: 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.
• Transfer of Medical Records Authorization (MEMORIAL): This form gives the Memorial office access to your previous medical records.
• Transfer of Medical Records Authorization (CYPRESS): This form gives the Cypress office access to your previous medical records.
• Transfer of Medical Records Authorization (KATY): This form gives the Katy office access to your previous medical records.
• Transfer of Medical Records Authorization (WOODLANDS): This form gives the Woodlands office access to your previous medical records.
• Transfer of Medical Records Authorization (FAIRFIELD): This form gives the Fairfield office access to your previous medical records.
• Transfer of Medical Records Authorization (GREATER HEIGHTS): This form gives the Greater Heights office access to your previous medical records.
• Transfer of Medical Records Authorization (SIENNA): This form gives the Sienna office access to your previous medical records.
• Transfer of Medical Records Authorization (SUGAR LAND): This form gives the Sugar Land office access to your previous medical records.
• Notice of Privacy Practices: This document explains how patient’s health information will be used and disclosed.
• Office Policy: This document explains Blue Fish’s policy regarding office visits.
• Patient Financial Responsibility Agreement: This form explains our financial responsibility policy for the services rendered at Blue Fish Pediatrics.

If you have any questions or concerns about these forms, please contact your location.