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Tower Hamlets lymphoedema referral form

Please complete all the required boxes. Details which are missing will result in the referral being rejected. WE NO LONGER ACCEPT HAND WRITTEN REFERRALS.

On full completion, please email to pZ4V=FB5GE1?[8W'Q}vLHmyu2]#[_@{6.8Kq%!q'A#5w3=e18vh[%.

You must provide a comprehensive medical history to support assessment. It is sufficient to attach an EMIS summary.

 Fully Mobile
 Mobile with Aids
 Wheelchair User
 Lymphorrhoea (wet legs)

Accelerate CIC lymphoedema referral criteria guide

Service description 

The service operates Monday-Friday, 09.00-17.00 and aims to support any patient who meets the defined and agreed referral criteria. Below is a simple guide, outlining the three indications for referral that must be met:

Referrals accepted: 

✓ Patient has at least one of the following: 

✓ Systemic causes have been ruled out

Referrals not accepted:

Known ischaemia of the affected limb 

x Varicose veins

x Routine Doppler in the absence of swelling 

x Venous or other ulceration 

Unstable cardiac/renal failure 

x Absence of swelling