Caring for your health
Ko'olau Radiology, Inc
1380 Lusitana Street, Suite 200, Honolulu, HI 96813
Phone: 808-599-4471 Fax: 808-523-3849
Richard L. DeJournett, M.D.
Queen’s Physician Office Building I
1380 Lusitana Street, Honolulu, Hi 96813
I, _________________________________________________ Date of Birth _____________________________
understand that these x-ray films are the property of Ko'olau Radiology at the Queen’s POB I, and that these films constitute part of my permanent records.
These films are being released for consultation to ______________________________________________ who is located at _______________________________________.
(Physician/ Specialist) (Address)
TYPE OF EXAM’S DATE OF EXAM’S
This medical information is strictly confidential and is for the information of the person to whom it is addressed. No responsibility can be accepted if it is made available to other persons.
Signed: ________________________________________ Date: _______________________ Contact Phone Number: ______________________________________________
Please fax completed form to 808-523-3849 or drop it off at our office.
Medical Records Request