Lymphoedema referral

Make your lymphoedema NHS referral here

Please contact us by phone rather than email during the Microsoft outage 020 3819 6022 and do not submit referrals until things are back up and running.

Referrals will not be accepted if any of the sections of the below form are incomplete or if the referral criteria are not met.

A comprehensive medical history must also be provided a within the referral form or as an attachment such as an RIO, EMIS or SystmOne summary.

Speak to our team

We can help with any referral questions you may have.

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020 3819 6022
weekdays
9am-2pm

Lymphoedema referral form Sept 2025

"*" indicates required fields

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

Yes

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

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*

Day

Month

Year

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

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
✔ Patients with lymphorrhoea or recent cellulitis must be known to the local pathway prior to referral to be eligible for transport
✔ Non-urgent patients requiring transport must have the ability to access the local pathway for follow-up or shared care after assessment if clinically required

TRANSPORT, MOBILITY AND ACCESS

✔ Ambulance transport is available only to patients within this area who meet the eligibility criteria for ambulance service provision
✔ Patients with lymphorrhoea or recent cellulitis must be known to the local pathway prior to referral to be eligible for transport
✔ Non-urgent patients requiring transport must have the ability to access the local pathway for follow-up or shared care after assessment if clinically required

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

Does the patient require transport to attend the clinic?*

Yes

Can the patient get into a car / taxi?*

Yes

Does the patient require an ambulance?*

Yes

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

Yes

Is the patient a bariatric patient?*

Yes

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

Please state the likely cause of swelling*

ABPI completed prior to assessment (lower limb only)*

Yes

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

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.

Together we’re transforming wound and lymphoedema care.
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Where to find us

Centenary Wing
St Joseph’s Hospice
Mare St, Hackney
London, E8 4SA
United Kingdom

Opening hours: 9am – 5pm

Tel 020 3819 6022
Weekdays 9am-2pm

Patient and Healthcare Professional enquiries acceleratecic.patient.queries@nhs.net

Referral Enquiries acceleratecic.accelerate@nhs.net

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