Yuri Peterkin, MD
Mahogany Ambrose, MD

MRI Referral Requisition

9149 Estate Thomas
Paragon Medical Building, Suite 103
St. Thomas, U.S. Virgin Islands 00802
Phone: (340) 774-0265 • Fax: (340) 776-0228
www.radiology.vi

Patient Name

Date of Birth

Gender
Male Female

Clinical Information / Diagnosis or Symptoms (PLEASE do not use R/O)

Extremity

MR Angiography

Brain w/o contrast

Carotids with contrast

Renals with contrast

Peripherals/Legs/Runoff

Utilize Contrast per Radiologist Discretion

Other

Other

Please note, cancer patients should have MRI of head/chest/abdomen/spine with and without contrast

Please report approximately 30 minutes prior to appointment time. NO Metal or jewelry can be worn in the machine.
Please bring X-rays or CT scans if you have them.
Please be sure to bring your insurance card and photo ID.
If you are unable to keep your appointment, please notify us 24 hours in advance, if possible.
The examination will take apporoximately 1 hour.
Patient MUST notify us if they have a pacemaker, glucose monitor, hearing aid or any implanted device at time of scheduling.

Clinician Name

Clinician Email*

* Upon submittal, an email will be sent to this address that will include this completed form.

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Date

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