Specialist treatment: Lymphoedema referral to a clinical specialist

Has the patient consented to this referral (and the sharing of all included details)?*

Yes
No

Area*

Please state your area*

REFERRAL CRITERIA

CRITERIA FOR REFERRAL ACCEPTANCE
The patient has at least one of the following:
✔ Chronic oedema / lymphoedema
✔ History of repeated cellulitis related to oedema (at least one episode of cellulitis within the last 3 months)
✔ Wet and weepy skin (lymphorrhoea)
✔ Primary lymphoedema (genetic or family)
✔ Secondary lymphoedema because of cancer or cancer treatment
Referrals will be accepted if:
✔ Systemic causes have been ruled out (heart failure, advanced kidney disease, advanced liver disease
✔ Patients can travel independently to clinic

CRITERIA FOR REFERRAL REJECTION:
✘ Known ischaemia of the affected limb
✘ Varicose veins, in the absence of swelling
✘ Routine Doppler in the absence of swelling
✘ Venous or other ulceration
✘ Unstable cardiac / renal failure
✘ Absence of swelling
✘ Patient is housebound i.e. unable to leave their home at all or requires significant assistance to leave their home to attend their appointment

REFERRAL CRITERIA

CRITERIA FOR REFERRAL ACCEPTANCE
The patient has at least one of the following:
✔ Chronic oedema / lymphoedema
✔ History of repeated cellulitis related to oedema (at least one episode of cellulitis within the last 3 months)
✔ Wet and weepy skin (lymphorrhoea)
✔ Primary lymphoedema (genetic or family)
✔ Secondary lymphoedema because of cancer or cancer treatment
Referrals will be accepted if:
✔ Systemic causes have been ruled out (heart failure, advanced kidney disease, advanced liver disease
✔ Housebound patient is known to the Community Nursing Team for a first line assessment (transport is not provided to our community clinics)

CRITERIA FOR REFERRAL REJECTION:
✘ Known ischaemia of the affected limb
✘ Varicose veins, in the absence of swelling
✘ Routine Doppler in the absence of swelling
✘ Venous or other ulceration
✘ Unstable cardiac / renal failure
✘ Absence of swelling
✘ Patient is housebound and not known to community services

REFERRAL CRITERIA

CRITERIA FOR REFERRAL ACCEPTANCE
The patient has at least one of the following:
✔ Chronic oedema / lymphoedema
✔ History of repeated cellulitis related to oedema (at least one episode of cellulitis within the last 3 months) ✔ Wet and weepy skin (lymphorrhoea)
✔ Primary lymphoedema (genetic or family)
✔ Secondary lymphoedema because of cancer or cancer treatment
Referrals will be accepted if:
✔ Systemic causes have been ruled out (heart failure, advanced kidney disease, advanced liver disease

CRITERIA FOR REFERRAL REJECTION:
✘ Known ischaemia of the affected limb
✘ Varicose veins, in the absence of swelling
✘ Routine Doppler in the absence of swelling
✘ Venous or other ulceration
✘ Unstable cardiac / renal failure
✘ Absence of swelling
✘ Patient is housebound

OBESITY
Where obesity is a contributing factor to lymphoedema and the patient has declined or is unwilling to engage in weight reduction measures, the range of therapeutic options available through the service may be limited.

SWELLING IS MILD
If the swelling is mild, please consider recommended primary care early-stage pathway

Criteria Selection*

PATIENT INFORMATION

Patient's Title*

Patient's Name*

Patient's Gender*

Patient's Date of Birth*

Patient's NHS Number*

Patient's Address*

Street Address Address Line 2 City Post code

Patient's Primary Phone Number*

Patient's Email Address

Patient's Ethnicity*

Translation Needed?*

Yes
No

Language*

REFERRAL INFORMATION

Referral made by?*

Referrer Name*

Referrer Email*

Referrer Phone Number*

Referrer Address*

Street Address Address Line 2 City Post code

Please provide a summary of the first line assessment and treatment to date*

GP Name*

GP Practice*

GP Phone Number*

GP Generical Email Address*

GP Address*

Street Address Address Line 2 City Post code

TRANSPORT, MOBILITY AND ACCESS

Transport will be arranged for patients that need it - typically those with a mobility impairment or fitting within a frailty category.

MOBILITY AND ACCESS

Patients need to be able to attend our clinic independently as transport is not provided. For housebound patients, they must already be known to the Community Nursing Team for us to be able to provide treatment.

Mobility Status*

Fully Mobile
Housebound
Mobile with aids
Wheelchair User

Mobility Status*

Bedbound
Fully Mobile
Housebound
Mobile with aids
Wheelchair User

Is the patient able to attend the clinic independently?*

Yes
No

Does the patient require transport to attend the clinic?*

Yes
No

Can the patient get into a car / taxi?*

Yes
No

Does the patient require an ambulance?*

Yes
No

Can the patient safely transfer independently from the transport to the clinic?*

Yes
No

Is the patient a bariatric patient?*

Yes
No

PATIENT MEDICAL HISTORY

Tick all which apply regarding urgency*

Wet and weepy skin (Lymphorrhoea)
Cellulitis
Palliative
None
Other

State the other issue*

Severity of swelling*

Is there a likely cause for swelling identified?*

Yes
No

Please state the likely cause of swelling*

ABPI completed prior to assessment (lower limb only)*

Yes
No

Explain why ABPI has not been completed*

Provide ABPI results*

Information on site of swelling, approximate onset, skin conditions (intact, leaking, ulceration etc), any acute inflammatory episodes*

Current medication (please state if none)*

Any allergies, adverse reactions or sensitivities? (please state if none)*

Cancer type and site (if any)*

Yes
No

Specify all surgical procedures, chemotherapy and radiotherapy treatments the patient has received, along with corresponding dates*

Other medical conditions (e.g. vascular disease, injuries, diabetes, etc)

Any additional information (e.g. access information or identified risk to lone workers, safeguarding concerns or mental capacity)

Photo/s of body area/s (if available)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, heic, Max. file size: 50 MB.

Medical summary (e.g. EMIS, RIO or SystemOne patient summary)*

Drop files here or

Accepted file types: pdf, doc, jpg, jpeg, png, heic, Max. file size: 50 MB, Max. files: 20.

You can upload your EMIS files here or email as per the details below.

Lymphoedema referral

Speak to our team

Lymphoedema referral form Sept 2025

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Lymphoedema referral

Speak to our team

Lymphoedema referral form Sept 2025

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