Hi Charlene & Nancy!I followed the style of the rack card template (generally) for the forms.

- Clean simple style - Making things flush left rather than centered when possible- All caps header text- Minimize use of boxes and lines around text- Minimize bolding when possible

As for content, I didn’t want to delete anything, so all forms were pretty much typed out verbatim. (Then I figured you could cut/change/move copy once you see it.)

It would be great if we could design these so that all the Patient information section of the forms were the same, and all the bottom sections were standardized too with the Dr. signature / comments section at the bottom.

What makes this difficult is that some of the forms are pret-ty packed with info, and spacing is tight. Thanks,Looking forward to your changes.

Jesse

808.721.9088 /// j@klineworks.com /// 1221 Victoria St. #1602 /// Honolulu, Hawaii /// 96814 /// klineworks.com

APPOINTMENT DATE: APPOINTMENT TIME: ARRIVAL TIME: ❒ Hospital : 98-1079 Moanalua Road, Aiea, HI 96701❒ Pavilion: 98-1005 Moanalua Road, Aiea, HI 96701

❒ Call Patient to Schedule Appointment ❒ Fax Back Appointment ConfirmationPlease check in at the Registration Department if you have not pre-registered.

Name: Phone # Cell # Date of Birth: Weight # Is patient pregnant? ❒ Yes ❒ NoAuthorization # ❒ Pending ❒ Waived ❒ No Authorization Needed

❒ Asthma ❒ Diabetes ❒ Allergies Please Specify____________________________________________________

Ordering Physician: Signature Print Name Date Time Office Contact:Print Name Phone # Fax # ❒ “STAT Reading” requested Copy of Reports to (print names):

**PLEASE FAX CLINICAL NOTES IF APPLICABLE**Diagnosis: ICD Codes(s): Signs and Symptoms: History: ❒ CD

❒ CT ❒ CTA Constrast: ❒ Radiologist Preference ❒ IV ❒ Oral ❒ None ❒ Brain ❒ Orits ❒ Abdomen ❒ KUB ❒ Soft Tissue Neck

❒ Sinuses ❒ Chest ❒ IVP ❒ Pelvis ❒ Spine

Other

❒ MRI CALL TO SCHEDULE AT 485-4424, FAX: 485-3148 Constrast: ❒ Radiologist Preference ❒ IV ❒ Oral ❒ None❒ BRAIN MRA ABDOMEN UPPER EXTREMITIES LOWER EXTREMITIES

❒ BREAST ❒ Brain ❒ Liver ❒ Shoulder ❒ Femur ❒ Foot

❒ ORBITS ❒ Neck ❒ Pancreas ❒ Elbow ❒ Knee ❒ Toes

❒ SPINE ❒ Chest ❒ Renal ❒ Wrist ❒ Hip

❒ Cervical ❒ Abdomen ❒ MRCP ❒ Hand ❒ Tib/Fib

❒ Lumbar ❒ Fingers ❒ Ankle

❒ Thoracic Other

OUTPATIENT REQUEST FORM CT / MRI IMAGINGTEL: 485 - 4222 | FAX: 485 - 4233

PMWC REV 07-2017

Date Scheduled: Procedure Time: ❒ Register 2nd floor of hospital at: Patient Name: Date of Birth: Home Phone: Work Phone: Cell Phone: Height: Weight: Primary Insurance: Authorization#: Allergies ❒ Yes ❒ No Asthma ❒ Yes ❒ No Pregnant ❒ Yes ❒ No Breastfeeding ❒ Yes ❒ NoMedications:

ECHOCARDIOGRAM ❒ FULL / LIMITED (follow up) ❒ STRESS Echocardiogram ❒ Treadmill ❒ Pharmacologic

REASON / CLINICAL QUESTIONGeneral Evaluation❒ R07.2 Precordial Chest Pain❒ R07.9 Chest Pain❒ R07.89 Chest Pain, unspecified❒ R06.02 Shortness of breath❒ R00.0 Tachycardia, unspecified❒ R00.1 Bradycardia❒ R00.2 Palpitations❒ I63.9 Stroke❒ I51.7 / R94.31 Cardiomegaly by❒ CXR or EXG or CT❒ R01.1 Cardiac murmur❒ R55 Syncope Heart Failure❒ I50.9 Congestive Heart Failure -initial evaluation❒ I42.0 Cardiomyopathy ❒ I11.0 Hypertensive heart disease with heart failure❒ I11.9 Hypertensive heart disease❒ Z01.818 Use of Cardiotoxic agent (chemotherapy)

HEART MONITORING❒ 24-Hour Holter Monitoring❒ Cardiac Event Monitoring ❒ TREADMILL ONLY (No Scan) ❒ CARDIAC MRI

Arrhythmia ❒ I49.3 Frequent PVCs or exercise-induced PVCs❒ I48.0 Paroxysmal Atrial Fibrillation❒ I48.91 Atrial fibrillation❒ I47.19 Supraventricular tachycardia (SVT) ❒ I47.2 Ventricular tachycardiaExtracardiac Chambers/Others❒ I31.9 Pericarditis / Pericardial effusion❒ I51.89 Cardiac mass❒ I77.810 Aortic root dilation❒ Q24.9 Congenital heart disease ❒ I38 EndocarditisMyocardial Infraction❒ I21.01 MI involving left main❒ I21.02 MI involving LAD❒ I21.11 MI involving RCA❒ I21.21 MI involving LCx❒ I21.4 NSTEMI❒ I25.2 Old MI

MYOCARDIAL EXAMS❒ NM Myocardial Perfusion Scan(Select one of the following): ❒ Treadmill ❒ Regadenoson(Lexiscan) ❒ Dobutamine

Coronary Atheroclerosis (ASHD)❒ I25.10 Native Artery without Angina❒ I25.810 Bypass Grafts without Angina❒ I25.89 Chronic Ischemic Heart Disease ❒ I25.5 Ischemic Cardiomyopathy ❒ I42.0 Dilated Cardiomyopathy❒ I48.1 Persistent Atrial Fibrillation❒ I48.2 Chronic Atrial Fibrillation ❒ I49.01 Ventricular Fibrillation❒ I49.5 Sick Sinus Syndrome❒ I50.1 Left Heart Failure❒ I51.7 Cardiomegaly❒ R94.31 Abnormal ECG❒ Z01.810 Preoperative Evaluation

Other:

Special Instructions: Copy of Report to: Ordering Physician: Phone Number: Fax Number: Ordering Physician’s Signature: Date: Time:

FAX THIS REQUEST WHEN COMPLETED TO 485-4214

OUTPATIENT REQUEST FORMCARDIAC SERVICES Echocardiogram & Holter Monitoring Scheduling: (808) 535 - 7000

Myocardial Exams Scheduling: (808) 485 - 4607Stress Echo & Cardiac Event Monitoring Scheduling: (808) 485 - 4210 Fax: (808) 485 - 4214

PMWC REV 07-2017

PATIENT INFORMATIONLast Name First Name Date of Birth Social Security #

Home Phone Cell Phone Work Phone

Mailing Address City State Zip

Alternate Contact (Name)

Primary Insurance Subscriber Group# Policy#

Secondary Insurance Subscriber Group# Policy#

Clinical Indication / ICD-10 Coverage Code Onset Date

BREAST SURGEON

❒ Briana Lau-Amii, MD ❒ Maria R. Ver, MD ❒ James Kakuda, MD ❒ Other

Surgeon visit will be followed up with an appointment with Survivorship Nurse Practitioner and Patient Navigator.

REASON FOR REFERRALReferring Physician (Print Name) Phone Physician’s Signature Date Copies of Report to Phone Fax

❒ Patient Preference Please check one or more of the following

RADIATION ONCOLOGISTCANCER CENTER OF HAWAI’I

❒ Laeton J. Pand, MD, MPH ❒ Susie A. Chen, MD ❒ John L. Lederer, MD ❒ Richard Y. Lee, MD Ph.D. ❒ Other

MEDICAL ONCOLOGIST ❒ Galen Choy, MD ❒ Other

PLASTIC SURGEON ❒ Helen Hui-Chou, MD ❒ Other

Survivorship ❒ Robin Easley, NP

Genetic Counseling ❒ Sandra Dreike, MS, CGC

Physical Therapy ❒

High Risk Breast Program ❒ Minkeo Kaisho, NP

Navigation ❒ Yolanda Racca, RT Navigator ❒ Noe McGuire, RN Navigator

OUTPATIENT REQUEST FORMCOMPREHENSIVE BREAST CENTER - APPOINTMENTS: (808) 485-4500 | PHONE: XXX-XXXX | Fax: (808) 485-4505

Once an appointment is made, please fax completed form.

PMWC REV 07-2017

Date Scheduled: Procedure Time: ❒ Register 2nd floor of hospital at: Patient Name: DOB: Home Phone: Work Phone: Cell Phone: Height: Weight: Medical History:

❒ Echocardiogram - FULL ❒ Echocardiogram - LIMITED (follow up) ❒ STRESS Echocardiogram ❒ Treadmill ❒ Pharmacologic

Reason/Clinical QuestionGeneral Evaluation ❒ R07.9 Chest pain ❒ R07.89 Chest pain, unspecified ❒ R06.02 Shortness of breath ❒ R00.0 Tachycardia, unspecified ❒ R00.1 Bradycardia ❒ R00.2 Palpitations ❒ G45.9 TIA / TIA with bubble study ❒ I63.9 Stroke ❒ I74.2 Embolic infraction (peripheral embolic event) ❒ I51.7 / R94.31 Cardiomegaly by CXR or ECG or CT ❒ R01.1 Cardiac murmur ❒ R55 Synoscope Heart Failure ❒ I50.9 Congestive Heart Failure - initial evaluation ❒ I38 Heart failure due to valve disease ❒ I42.9 Cardiomyopathy ❒ I50.9 Heart failure (unspecified) ❒ I10 Essential (primary) Hypertension ❒ I11.9 Hypertensive heart disease ❒ Z01.818 Use of cardiotoxic agent (chemotherapy) Arrhythmia ❒ I49.3 Frequent PVCs or excercise-induced PVCs ❒ I48.0 Paroxysmal Atrial Fibrillation ❒ I48.91 Atrial fibrillation ❒ I47.19 Superventricular tachycardia (SVT) ❒ I47.2 Ventricular tachycardiaExtracardiac Chambers/Others ❒ I31.9 Pericarditis / Pericardial effusion ❒ I31.4 Tamponade ❒ I51.89 Caridac mass ❒ I77.810 Aortic root dilation ❒ Q24.9 Congenital heart disease ❒ I38 Endocarditis

Pulmonary Hypertension (PHTN) I27.0 ❒ Pulmonary hypertension ❒ Routine surveilance (≥ 1 year from last echo) ❒ PHTN with change in clinical statusValvular Heart Disease ❒ I38 AA Initial evaluation with Vulvular Heart Disease ❒ Z86.79 Re-evaluation of valve disorder for a change in clinical

status ❒ Moderate/sever valvular stenosis with no symptoms

≥ 1 year from last echo (Circle all that apply: I38 aortic I05.0 mitral I07.0 tricuspid I37.0 pulmonic)

❒ Mid valvular stenosis ≥ 3 years from last echo (Circle all that apply: I38 aortic I05.0 mitral I07.0 tricuspid I37.0 pulmonic)

❒ Moderate/severe valvular regurgitation with no symptoms ≥ 1 year from last echo (Circle all that apply: I38 aortic I05.0 mitral I07.0 tricuspid I37.0 pulmonic)

❒ Initial evaluation of prosthetic heart valve (Circle all that apply: I38 aortic I05.0 mitral I07.0 tricuspid I37.0 pulmonic)

❒ Routine surveillance of prosthetic valve ≥ 3 years from last echo (Circle all that apply: I38 aortic I05.0 mitral I07.0 tricuspid I37.0 pulmonic)

❒ Prosthetic valve with valve dysfunction (Circle all that apply: 105.0 aortic I05.0 mitral I07.0 tricuspid I37.0 pulmonic)

Other:

Special Instructions: Copy of Report to: Ordering Physician: Phone Number: Fax Number: Odering Physician’s Signature: Date: Time:

FAX THIS REQUEST WHEN COMPLETED TO 485-4214

OUTPATIENT REQUEST FORMECHOCARDIOGRAM Scheduling: (808) 535 - 7000 Phone: (808) 485 - 4398

PMWC REV 07-2017

Appointment Date: Appointment Time: Patient Name: Date of Birth: G: P: Requesting /Referring Physician: Office Phone Number:

PROCEDURE REQUESTED (please check all that apply):

❒ Complete Gyn Ultrasound 920074 (transabdominal and transvaginal ultrasound)

❒ Transabdominal Gyn Ultrasound only 76856

(transvaginal ultrasound will not be done) ❒ Doppler (pelvic organ/ovary) 96976 ❒ 2D Sonohysterography (saline infusion sonography/SIS) of uterus

76813, 58340 (Indicated for evaluation of possible polyps, sub-mucous myomata, etc.)

** SIS procedures will not be performed if there is a possibility of pregnancy, if there is a current pelvic infection (PID), or if an IUD is present in the uterus. In a woman with regular menstrual cycles, SIS should not be scheduled later than the 10th day of the menstrual cycle. Please see patient information sheet “How to prepare for a sonohysterography” provided by KMCWC.

❒ 3D Sonohysterography (saline infusion sonography/SIS) of uterus 76831, 58340, 76376 (Indicated for evaluation of possible congenital uterine anomalies) ❒ 3D ultrasound of uterus without SIS 76376 (Indicated for IUD localization)

❒ If the physician sonologist recommends additional ultrasound services, do you want us to order and schedule the service? ❒ Yes ❒ No

COMMENTS:

GYN Ultrasounds are performed

at our Fetal Diagnostic Center

on the 5th floor.

OUTPATIENT REQUEST FORM GYN ULTRASOUNDAPPOINTMENTS: 535 - 7000 | PHONE: 983 - 8559 | FAX: 485 - 4505

Once an appointment is made, please fax completed form.

FETAL DIAGNOSTIC CENTER1319 Punahou Street | Honolulu, Hawai’i 96826

T 808.983.8559 | F 808.983.8989 | Kapiolani.org

PHYSICIAN’S SIGNATURE:

Appointment Request Information:Currently pregnant? ❒ Yes ❒ No Gravida Para SAB EAB Living Stillborn

LMP EDD Date of first U/S Gestational age of U/S

Height Weight Blood Type MCV Is the patient aware of this request? ❒ Yes ❒ No

Service(s) requested: ❒ Nuchal Translucency Ultrasound (w/ FBR Lab Requisition)❒ Endovaginal ( ❍ Cervical Length ❍ Dating/Visibility ≤14 wks )❒ Targeted Morphology (Level 2) Ultrasound❒ Growth (EFW/Growth) - Singleton❒ Growth (EFW/Growth) - Multiples❒ Biophysical Profile❒ Doppler Studies ( ❍ MCA ❍ UA )

❒ Genetic Counseling❒ Maternal-Fetal Medicine Consultation ❒ Transfer of Obstetric Care❒ Fetal Echocardiogram❒ Amniocentesis (w/ Ultrasound)❒ Chronic Villus Sampling (Manchester only) w/ Ultrasound❒ Other:

PMWC REV 07-2017

PMWC REV 07-2017

OUTPATIENT REQUEST FORM BREAST, ULTRASOUND & DEXA SERVICES

Please schedule (Patient Name)________________________________________for the following services.Date of Birth_________________ Patient is confirmed for: Date_______ Time ________

SCREENING SERVICES❒ Screening mammogram only❒ Screening mammogram follow-up ❒ Screening Breast Ultrasound ❒ MRI ❒ Tom synthesis❒ DEXA-hip and spine

DIAGNOSTIC SERVICES (clinical finding or concern)❒ Diagnostic mammogram with breast ultrasound and for breast tom synthesis if needed

❒ Right ❒ Left (check one or both)

❒ Diagnostic breast ultrasound ❒ Right ❒ Left (check one or both)

❒ Bilateral Breast MRI without IV contrast (implant evaluation)❒ Bilateral Breast MRI with IV contrast

❒ Ultrasound – Pelvic❒ Ultrasound – Pelvic w/ transvaginal❒ Ultrasound – Sonohysterography

INTERVENTIONAL TESTS❒ Stereotactic core biopsy ❒ Right ❒ Left❒ Ultrasound guided core biopsy/cyst aspiration ❒ Right ❒ Left❒ Mammography needle localization ❒ Right ❒ Left❒ Ultrasound needle localization ❒ Right ❒ Left❒ Galactography ❒ Right ❒ Left❒ Patient navigation

Reason for Exam/ICD? Comments: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Indicated problems:

* REQUIRED FOR SERVICES- MARK PALPABLE AREA, OR AREA OF CONCERN, BELOW

Right Left

PHYSICIAN’S NAME (Please print full name)____________________________________________________________________Physician’s Signature (Required)__________________________________________________Date_________________________Phone Number_____________________________ Fax Number _____________________________________________________CC Physician ___________________________________ Authorization: _______________________________________________

Call Health Connection at 535-7000 to schedule an appointment.(Physician offices press 3 to be directly connected to a scheduler.)

OUTPATIENT REQUEST FORMBREAST, ULTRASOUND & DEXA (EZ-FAX)Questions: Call (808) 535-7000 and press 3.Complete Exam by______________________ If you need a same day appointment for a new finding, please call (808) 465-4500 and press 2. Do not use this form.To schedule your patient, simply fax us this form. We will call your patient and schedule the appointment. Once complete, we will fax this form back to you confirming the appointment has been scheduled.Patient is confirmed for: Date ________ Time ___________________PATIENT INFORMATIONLast Name _____________________________ First Name _________________________________________________________Date of Birth ___________________________ Home Phone _________________ Cell Phone ____________________________Alternative Cantact: (Name) ____________________________ Phone Number _______________________________________

INSURANCE INFORMATIONPrimary Insurance _____________________________________ Secondary Insurance __________________________________

PROCEDURE REQUESTED:❏ Screening Mammogram With Screening Breast US With Tomosyntesis❏ Additional views❏ Diagnostic Mammogram With Ultrasound as indicated by radiologist

Diagnosis or reason for exam: _____________________________________

❏ Ultrasound ❏ Bilateral ❏ UnilateralDiagnosis or reason for exam:

Indicated problems:

* REQUIRED FOR SERVICES- MARK PALPABLE AREA, OR AREA OF CONCERN, BELOW

Right Left

FAX TO: (808)

535-7922

PHYSICIAN’S NAME (Please print full name)__________________________________________________________________ Physician’s Signature (Required)__________________________________________________Date________________________Phone Number_____________________________ Fax Number ____________________________________________________CC Report to: ______________________________________________________________________________________________

❒ Ultrasound – Pelvic❒ Ultrasound – Pelvic w/transvaginal❒ Ultrasound – SonohysterographyDiagnosis or reason for exam:____________________________________❒ DEXA Hip & Spine (Table limit is 300lbs.)❒ DEXA Peripheral Forearm due to technical or patient

limitations.❒ If patient has Medicare (expept A & B),please check one:❒ Screening ❒ Monitoring*Please note if special accommodations required:_____________________________________________________

REASON FOR EXAM, PLEASE INCLUDE ICD IF AVAILABLE: _____________________________________________________❒ Post-Menopausal with contributing factors: ❒ Current Smoker ❒ Low weight <127 lbs. or BMI 20 or less ❒ Surgical or natural menopausal before age 40 ❒ History of low impact fracture after age 45 in first

degree relative

❒ Osteoporosis Unspecified❒ Drug inducted osteoporosis❒ Adrenal Corticosteroids❒ Long term steroids use❒ Senile osteoporosis (post menopause)❒ Idiopathic osteoporosis❒ Disuse osteoporosis❒ Osteopenia❒ Other______________________________________________

R L_____ _____ Idiopathic osteoporosis_____ _____ Disuse osteoporosis_____ _____ Osteopenia_____ _____ Other_________________________

PMWC REV 07-2017

Patient Name __________________________ Date of Birth _______________ Authorization #___________________________Home Phone _____________ Work Phone __________ Primary Insurance ___________________________________________ Date Schedule________ Procedure Time ____________ Height ___________ Weight _________Allergies ❒ Yes ❒ No Asthma ❒ Yes ❒ No Pregnant ❒ Yes ❒ No Breastfeeding ❒ Yes ❒ NoAllergies Medications

MYOCARDIAL EXAMSMyocardial Exams Prep: • No Caffeine 24hours prior to test. • Nothing by mouth after midnight • If Diabetic, please eat a small breakfast (toast, juice).❒ Treadmill only (No Scan)❒ NM Myocardial Perfusion Scan (Select one of the following):

❒ Treadmill ❒ Regadenoson (Lexi scan) ❒ DabutamineDiagnosis for Myocardial exams:❒ R07.2 Precordial Chest Pain❒ R07.09 Chest Pain, unexpected❒ I11.0 Hypertensive heart disease

With heart failure❒ I11.9 Hypertensive heart disease

Without heart failure❒ I21.01 MI Involving left main❒ I21.02 MI Involving LAD❒ I21.11 MI Involving RCA❒ I21.21 MI Involving LCx❒ I1.21.4 NSTEM❒ I25.2 Old MI❒ Other ________________________

NON –MYOCARDIAL EXAMS❒ NM Bone Scan: 3 Phase ❒ NM Bone Scan: Multiple❒ NM Bone Scan: Whole Body❒ NM Breast Sentinel ❒ NM Gastric Emptying❒ NM HAD Scan❒ NM HAD Scan with CCK

Diagnosis___________________________________________________________________________________________________

LABORATORY TESTSFor Renal Exam: Date of Lab Test_______________ Bun______________ Creztinine___________________________________For Thyroid Exam: Date of Lab Test______________ TSH______________ fT4_________________________________________Copy of Report to___________________________________________________________________________________________Ordering Physician____________________________ Phone Number________________ Fax number _____________________Ordering Physician’s Signature __________________ Date______________ Time________________________________________Special Intructions____________________________________________________________________________________________

OUTPATIENT REQUEST FORMNUCLEAR MEDICINEAPPOINTMENTS: 535 - 7000 | PHONE: 983 - 8559 | FAX: 983 - 8989

Once an appointment is made, please fax completed form.

Coronary Atherosclerosis (ASHD)❒ I25.10 Native Artery without Angina❒ I25.110 Native Artery with Angina❒ I25.810 Bypass Grafts without Angina❒ I25.09 Ischemic Heart Disease❒ I25.5 Ischemic Cardiomyopathy❒ I42.0 Dilated Cardiomyopathy❒ I48.8 Other Cardiomyopathy❒ I48.0 Paroxysmal Arial Fibrillation❒ I48.1 Persistent Arial Fibrillation❒ I48.2 Chronic Arial Fibrillation❒ I49.01 Ventricular Fibrillation❒ I49.5 Sick Sinus Syndrome

❒ NM Lung VQ❒ NM MUGA Scan❒ NM Parathyroid imaging❒ NM Renal with Captopril❒ NM Renal with Lasix❒ NM Renal: Non Pharmacologic❒ NM RX Thyroid CA Ablation

❒ NM Thyroid CA METS: Whole Body❒ NM Thyroid Imaging: Only❒ NM Thyroid Update & Scan❒ Other:_________________________ ___________________________________________________________________________________________________

PMWC REV 07-2017

NUCLEAR MEDICINE 98-1079 Moanalua Rd., ‘Aiea, HI 96701 TEL: (808)485-4607 FAX: (808)485-4233

❒ 24-hour Holter Monitoring To schedule call: (808) 535-7000

❒ I50.1 Left Heart Failure❒ I51.7 Cardiomegaly❒ R55 Syncope❒ R00.0 Tachycardia, unexpected❒ R00.2 Palpitation❒ R06.02 Shortness of Breath❒ R94.31 Abdominal ECG❒ Z01.810 Preparative Evaluation

OUTPATIENT REQUEST FORMUS/X-RAY/FLOUROTel: 485.4222 / Fax 485.4233

PMWC REV 07-2017

APPOINTMENT DATE: APPOINTMENT TIME: ARRIVAL TIME: ❒ Hospital : 98-1079 Moanalua Road, Aiea, HI 96701❒ Pavilion: 98-1005 Moanalua Road, Aiea, HI 96701

❒ Call Patient to Schedule Appointment ❒ Fax Back Appointment ConfirmationPlease check in at the Registration Department if you have not pre-registered.

Name: Phone # Cell # Date of Birth: Weight # Is patient pregnant? ❒ Yes ❒ No

❒ Asthma ❒ Diabetes ❒ Allergies Please Specify____________________________________________________

Ordering Physician: Signature Print Name Date Time Office Contact:Print Name Phone # Fax # ❒ “STAT Reading” requested Copy of Reports to (print names):

**PLEASE FAX CLINICAL NOTES IF APPLICABLE**Diagnosis: ICD Codes(s): Signs and Symptoms: History: ❒ CD

❒ Ultrasound___________________________________❒ X-Ray_____________________________________________❒ Fluoroscopy Procedures/GI Procedures________________________________________

❒ Esophagram ❒ Barium Enema ❒ Arteriogram ❒ Myelogram ❒ UGI ❒ Modified Barium Swallow ❒ Lumbar Puncture ❒ VCUG ❒ UGI with SBFT ❒ HSG ❒ Cryptogram ❒ T-Tube Cholangiogram ❒ SBFT (small bowel follow through) ❒ IVP

Appointment Date:

Time:

• Check-in at least 15 minutes prior to your appoint-ment time.

• Wear a two-piece outfit to your appointment.

• Please DO NOT USE perfume, deodorant, powder, or other ointments, creams or bath oils.

• Contact your insurance company directly if you have question about your coverage.

If you need to reschedule your appointment, please contact us at (808) 535-7733.

Appointment Date:

Time:

• Check-in at least 15 minutes prior to your appointment time.

• Wear a two-piece outfit to your appointment. Do not wear clothing that has metal or metal accesories. Choose pants that have an elastic waistband.

• If you take calcium supplements, DO NOT take them for 24 hours prior to your test.

• Please DO NOT USE perfume, deodorant, powder, or other ointments, creams or bath oils.

• Contact your insurance company directlyif you have questions about your coverage.

If you need to reschedule your appointments, please contact us at (808) 535-7000.

PATIENT PREPARATION INSTRUCTIONS Bone Density/DEXA Scan

PATIENT PREPARATION INSTRUCTIONSFor Screening Mammogram,Tomosynthesis, Breast Ultrasound

PMWC REV 07-2017PMWC REV 07-2017

Pali Momi Street

Moa

nual

ua R

oad

Haukapila Street

Canal

Pearlridge

Toys R Us

Pali Momi Cancer Center(opening mid 2017)

Pali Momi Hospital

EmergencyServices

Pali MomiWomen’s

Center

Physician Clinics

Physician Specialty Suites

Women’s CenterRegistration

Imaging Center(MRI Suites)

InfusionServices

Financial OfficeRegistration

CoffeeKiosk

ImagingLaboratory

Surgery, Recovery, Ambulatory Care

Intensive Care

CardiovascularServices& NuclearMedicine

Doctors’ Offices

Doctors’ Offices

Valet

Valet

Drop-off

Dining Room Pharmacy

Gift Shop

InfoDesk

InfoDesk

Drop-off

Conference rooms

Conference rooms

Doctors’Offices

Doctors’Offices

Pali Momi Medical Pavillion

CaliforniaPizza Kitchen

First HawaiianBank

Bank of Hawaii(coming soon)

Ross

P

P

P

P

P

P

P

E

E

E

PE

PE

PE

PE

E

E

E

PE

E

E

E

E

E

E

EE

PE

PE

E

Chapel

Campus Pedestrian Walkway

Pedestrian Walkway

LowerLevel

Street Level

1

2

3

4,5,6Guest Rooms Visiting Hours 9am – 8:30pm

Campus Vehicle Driveway

Street

Parking$1 in Pali Momi Medical Center, with validationfree in lot behind Cancer Center free in lots near Medical Pavillion

Emergency Drop Off

Parking Elevator

Building Elevator

Entrance

Restroom

Shuttle Pick up to Medical Pavillion

INFORMATION TO COME

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