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Prime Medical
CT SCANS
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X-RAYS
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FLUOROSCOPY
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BARIUM STUDIES
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HSG SERVICES AVAILABLE
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RESULTS WITHIN 4 HOURS
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Emergency Scans Available
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(876) 926-2012
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All Insurance Plans Accepted
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Medical Services
[email protected]
(876) 665-6402
( 876) 926-2012
(876) 333-4163
Radiology Services
[email protected]
(876) 665-6402
(876) 926-2012
(876) 823-4492
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Date
*
PATIENT’S INFORMATION
Name:
*
First
Last
Age:
Sex:
*
Male
Female
Date of Birth:
Phone No:
Cell:
DOCTOR’S INFORMATION
Name
Phone
Email
*
Address
Fax
EXAMINATION REQUESTED(Please tick / indicate below)
Clinical History:
CT Scan
Abdomen
Abdomen & Pelvis
Brain
Chest
Chest & Abdomen
Chest, Abdomen & Pelvis
Facial Bones / Orbits
KUB
Neck
Pelvis
Sinuses
Spine C T L (circle one or more)
Temporal Bones
Urogram
Other
Other
*
CT Angiogram
Aorta
Carotids
Brain
Cerebal
pulmonary
Upper Limbs
Other
Other
*
Ultrasound
Abdomen
Arterial L R
Breast L R
Carotids – Bilatera
Eye
KUB
MSK
Obstetric
Pelvis
Scrotal
Thyroid
Venous Lower / Upper L R
Other
Other
*
Fluoroscopy
Barium Enema
Barium Mea
Barium Swallow
H.S.G
MCUG
Urethrogram
Other
Other
*
PROCEDURES
Biopsy
Colonoscopy (Virtual)
CT Guided Biopsy
Fine Needle Aspiration Cytology (FNAC)
Hysteroscopy
IUD insertion or removal
IV Fluids
Mass (lump) removal
Microneedling (Skinpen)
Nasal/nasopharyngeal endoscopy
Pap Smear
Prostate Biopsy
Ultrasound guided biopsy
Other
Other
*
X-Ray
Abdomen
Ankle L R
Chest
Elbow L R
Femur L R
Foot L R
Forearm L R
Hand L R
Hip L R
Humerus L R
Knee L R
KUB
Pelvis
Shoulder L R
Spine C T L
Tib/Fib L R
Wrist L R
OtheR
Other
*
MRA MRV
Brain
Carotid
Lower Limbs
Other
Other
*
MRI
Abdomen / MRCP
Ankle L R
Brain
Foot L R
Hip L R
IAMs
Knee L R
Orbits
Pelvis
Pituitary Fossa
Prostate
Shoulder L R
Spine C T L
Wrist/Hand L R
Other
Other
*
Report
Deliver
Email
Fax
Patient will pick up
Images
Referral Forms Required
Send CD
Send Films with Patient
DOCTORS BOOK AND USE OUR FACILITIES
Book use of our Medical Procedure Room
Book use of our Operating Theatre
Book use of Fluoroscopy suite
BLOOD TESTS
Hematology Panel:
HB, HCT, MCHC, TOTAL WBC (GRANULOCYTES, %GRANULOCYTES, LUMPS + MONOS, % LYMPHS + MONOS, PLATELETS)
CHEM8+(NA,K,Cl-, Anion gap, Ionised Ca2+, Glu,BUN, Cr,Hb,Hct, tot Co2)
E3 + (Na, K, Hb, Hct)
PT/INR
cTnl
CK-MB
Lipid panel (CHOL, CHOL/HDL*, nHDLc*, HDL, LDL*, TRIG, VLDL*)
Comprehensive Metabolic Panel
(ALB, ALP, ALT, AST, BUN, Ca, CI-, CRE, GLU, K+, Na+, TBIL, tCO2, TP
OTHER TESTS
Blood Glucose
Chlamydia & Gonorrhea (Rapid)
COVID 19 Antigen test
ECG
Echocardiogram
Employment Medical
HBA1c
HIV (Rapid)
HIV(Rapid) + Syphilis (VDRL)
Pregnancy test
School Medical
Other
Other
*
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