Outpatient Imaging Procedure Request Form - Kapi'olani Medical ... - kapiolani 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name in the designated fields for Last, First, and Middle Initial.
3. Fill in the Date of Service and Time of Exam to ensure accurate scheduling.
4. Provide the patient's Date of Birth and Home Phone number for identification purposes.
5. In the Procedure section, clearly specify the imaging procedure required.
6. Detail any relevant medical history related to the procedure in the History section.
7. Outline symptoms and chief complaints that justify this request, avoiding vague terms like 'routine'.
8. Indicate any questions you want answered regarding the procedure.
9. Complete the Physician Signature section, including your printed name, office phone, and fax number.
10. Select how you would like the report sent back by checking one of the options provided at the bottom of the form.

Start using our platform today to streamline your form completion process for free!