St. Thomas Radiology Associates, LLC
Yuri Peterkin, MD
Mahogany Ambrose, MD

CT Scan 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

Gender   
Extremity
Spine
CT Angiography
* Upon submittal, an email will be sent to this address that will include this completed form.
Signature of Clinician – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
LuxSci helps ensure HIPAA-compliance for email and web services.