Leg ulcer, foot ulcer and wound care specialist referrals

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

Yes
No

Area*

State your area*

REFERRAL CRITERIA

CRITERIA FOR REFERRAL ACCEPTANCE
The patient has at least one of the following:
✔ Leg ulceration
✔ Complex wound not progressing on the local pathway
✔ Approved by the local Tissue Viability Team
✔ Known to the local pathway

CRITERIA FOR REFERRAL REJECTION:
✘ Known ischaemia of the affected limb where vascular input has not been provided
✘ Varicose veins, in the absence of wounds or skin breaks
✘ Routine Doppler in the absence of a wound
✘ Diabetic foot ulcer
✘ Non-diabetic foot ulceration where a joint approach with foot health is required
✘ Pressure ulcer
✘ Housebound and not safe to transfer or travel

REFERRAL CRITERIA

CRITERIA FOR REFERRAL ACCEPTANCE
The patient has at least one of the following:
✔ Leg ulcer
✔ Non-healing surgical wound
✔ Other non-healing wound
✔ Deemed at high risk of venous ulcer recurrence and are unable to tolerate therapeutic compression (mobile leg ulcer patients must be maintained by primary care until the patient is booked into clinic).
✔ Pressure ulcer within a nursing home and primary care
Pre-requisite:
✔ Housebound patients who require a first assessment by Accelerate must be actively known to the Community Nursing Team or Primary Care Nurse to facilitiate a joint assessment (transport is not provided to our community clinics)

CRITERIA FOR REFERRAL REJECTION:
✘ Critical ischaemia of the affected limb not known to vascular
✘ Varicose veins, in the absence of wounds or skin breaks
✘ Routine Doppler in the absence of a wound
✘ Diabetic foot ulcer
✘ Other foot ulceration (a joint approach with foot health is required)
✘ Housebound pressure ulcer patients seen by ELFT

REFERRAL CRITERIA

CRITERIA FOR REFERRAL ACCEPTANCE
The patient has at least one of the following:
✔ Leg ulceration
✔ Complex wound not progressing on the local pathway
✔ Approved by the local Tissue Viability Team
Required as a prior condition:
✔ Known to the local pathway and there will be shared local care for all patients

CRITERIA FOR REFERRAL REJECTION:
✘ Known ischaemia of the affected limb where vascular input has not been provided
✘ Varicose veins, in the absence of wounds or skin breaks
✘ Routine Doppler in the absence of a wound
✘ Diabetic foot ulcer
✘ Non-diabetic foot ulceration where a joint approach with foot health is required
✘ Pressure ulcer
✘ Housebound and not safe to transfer or travel

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

Criteria Selection*

Please state your Criteria*

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

ABPI completed prior to assessment? (lower limb only)*

Yes
No
N/A

Provide ABPI results*

Provide a reason for not performing the ABPI as it is expected that this has been attempted as part of the local Leg Ulcer Pathway prior to referral*

Wound type

Leg ulcer
Erosions secondary to oedema
Surgical wound
Fungating wound
Skin tear
Traumatic wound
Burn
Pressure ulcer (nursing home ONLY)
Other

Please state Wound Type*

Wound Site

Please state Wound Site*

Relevant history for the wound/s*

Current wound management, medication and GP summary (please state if none)*

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

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)

Photos are extremely important to aid triage, determine urgency and aid remote clinical assessment. Are you able to provide us with photos to assist with assessment?*

Yes
No

Please upload your photos here

Drop files here or

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

Please select your reason/s for not supplying photograph/s*

Patient did not consent to photographs
No access to secure image capture tools (e.g. NHS compliant devices)
Other

Please state your reason*

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

Drop files here or

Accepted file types: pdf, doc, Max. file size: 50 MB, Max. files: 20.

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

Wound care referral

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Wound care referral form Sept 2025

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Wound care referral

Speak to our team

Wound care referral form Sept 2025

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