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

Patient Name

Date of Birth

Gender
Male Female

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

Extremity

Spine

Cervical

Thoracic

Lumbar

CT Angiography

Utilize Contrast per Radiologist Discretion

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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