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.                                        
Medical Director

Queen’s Physician Office Building I        
1380 Lusitana Street, Honolulu, Hi 96813    

Date:  __________________

I, _________________________________________________  Date of Birth _____________________________  
            (Patient’s Name)

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