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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 .HkQ$hDAE7F]9JlT*IdniOC4[]#[w*X1t^My!u'Jy9NIj`SW]X.tP.

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


 Yes
 No
 Yes
 No
 Bariatric
 Bedbound
 Fully Mobile
 Housebound
 Mobile with Aids
 Wheelchair User
 Yes
 No
 Lymphorrhoea (wet legs)
 Cellulitis
 Palliative
 Yes
 No
 

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