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Lymphoedema referral form for City & Hackney

Please complete the form below and click on the Submit button to make your referral to Accelerate CIC.

Please ensure all fields are completed and please also ensure all housebound patients are seen in the first instance by Community Services in advance of referral to the Lymphoedema Clinic


 Male
 Female
 Not stated
 Yes
 No
 Recurrent Cellulitis
 Lymphorrhoea (Leaky Legs)
 Known to Adult Community Nursing Service for Chronic Oedema/Lymphoedema
 Lymphoedema Secondary to Cancer
 Primary Lymphoedema
 Heart Failure
 Renal Disease
 Thyroid Disease
 Vascular Disease
 Deep Vein Thrombosis
 Chronic Skin Disorder
 Diabetes
 Rheumatoid Arthritis
 Low Serum Protein/Albumin
 Mobility Problems
 Fully Mobile
 Mobility Aid
 Housebound
 Confirm