Yuri Peterkin, MD
Mahogany Ambrose, MD

Women’s 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)

**Please have patients bring ALL prior outside mammograms and accompanying reports to appointment**

Women’s Health: MG / US / OB

BPP

OB Limited and BPP

Bone Densitometry (DEXA)

HSG - Hysterosalpingogram

Ultrasound Transvaginal / Endovaginal

HSS - Saline Infusion Sonography

Symptoms

Please indicate if the patient has any of the following symptoms
Focal point of pain
Palpable Mass      Skin Dimpling
Mastitis (redness/warmth)
Spontaneous Nipple Discharge
Other

Women’s Procedures

US Guided Breast / Cyst Aspiration

Uterine Fibroid Embolization

US Image Guided Breast Aspiration (Fluid Collection/Abscess)

MRI

Breast MRI

Breast Imaging Order Guide

INDICATION

1. FOCAL BREAST PAIN or PALPABLE IN FEMALE < 40 YEARS OLD
2. NIPPLE DISCHARGE IN FEMALE < 30

CORRECT ORDER(S) FOR SCHEDULING

Limited breast ultrasound ONLY
• Unilateral R or L
• Bilateral

INDICATION

FOCAL BREAST PAIN or PALPABLE IN FEMALE > 40
For any palpable lump only felt by ordering clinician during breast examination, an estimated size, clock face and distance from the nipple should be documented on the ordering sheet.

CORRECT ORDER(S) FOR SCHEDULING

Diagnostic mammogram (if > 6 months since last mammogram)
   • Unilateral R or L
   • Bilateral
- and -
Limited breast ultrasound
   • Unilateral R or L
   • Bilateral

INDICATION

BREAST PAIN or PALPABLE IN MALES > 25

CORRECT ORDER(S) FOR SCHEDULING

Diagnostic mammogram
   • Unilateral R or L
   • Bilateral
- and -
Limited breast ultrasound
   • Unilateral R or L
   • Bilateral

INDICATION

NIPPLE DISCHARGE in any MALE or FEMALE > 30
(milky/clear vs. bloody/brown)
(spontaneous vs. non-spontaneous i.e. expressed by squeezing)

CORRECT ORDER(S) FOR SCHEDULING

Diagnostic mammogram (if > 6 months since last mammogram)
   • Unilateral R or L
   • Bilateral
- and -
Limited breast ultrasound
   • Unilateral R or L
   • Bilateral

If you have any questions, please do not hesitate to call us at (340) 774-0265.

Clinician Name

Clinician Email*

* 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.

Date

LuxSci helps ensure HIPAA-compliance for email and web services.