Yuri Peterkin, MD
Mahogany Ambrose, MD

Procedure Referral Requistion

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

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

Musculoskeletal Procedures

Other Procedures

CT Guided Biopsy

CT Guided Drainage

CT Guided Paracentesis

Clinician Name

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