Referral Form
ALL SECTIONS MUST BE COMPLETED
PATIENT DETAILS
REASONS FOR REFERRAL
Surname
First name
Address
 Lymphoedema secondary to cancer /
cancer treatment.

If so, please tick the following if
relevant:
Postcode
Male / Female
Email
NHS Number
 Regional lymph node involvement
Telephone
DOB
Ethnicity
Hospital number
 Regional skin involvement
 Local recurrence
GP DETAILS
 Distant mets
Name
Address
 Lymphoedema secondary to venous
disease
 Lymphoedema secondary to limb
dependency / immobility
Postcode
Telephone
IS THE REFERRAL URGENT: Routine 
 Primary lymphoedema (congenital /
hereditary)

Urgent 
SEE FLOW CHART
GENERAL MEDICAL HISTORY
DIAGNOSIS (with dates if known)
Phlebitis
Varicose Veins
Rheumatoid Arthritis
Osteo-arthritis
Thyroid
Yes 
Yes 
Yes 
Yes 
Yes 
No 
No 
No 
No 
No 
Surgical Interventions
Yes  No 
Details
Weight:
Weight loss referral made: YES/NO
BMI:
Lymphoedema History: Oedema evident in: (please tick all appropriate)
Face 

Arm(s) 
Chest 
Abdomen 
Genitals 
Do you consider the oedema as Mild  Moderate  Severe 

Is the patient complaining of pain Yes  No  Site of pain:

Leg(s) 
Palliative 
Other 
Skin condition: Lymphorroea/leakage of lymph fluid
Intact
Ulcerated
Bandages
Wounds
Other skin changes, please state:
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 



Other professional involvement:
Tissue Viability Nurse/ Leg Club/ Practice Nurse/District Nurse
If lymphoedema is secondary to cancer please include copies of correspondence regarding diagnosis,
lymph node involvement, treatment received/planned
Assessment required: Clinic 
Home 
Nursing Home 
 Please note that transport is not provided
 Home visits will only be offered to housebound patients
ANY ADDITIONAL RELEVANT PAST / CURRENT MEDICAL HISTORY:
OTHER RELEVANT INFORMATION:
Mobility / access / communication / language barrier / translator required?
WHO COMPLETED THIS FORM?
Name (please print)
Position
Address
Postcode
Telephone
Email
Fax
Please tick to confirm you have included the following:
Results of blood for U & Es Thyroid functions FBCs 
Recent clinic letters GP Summary Current Medication List 
The above SHOULD BE EMAILED WITH THIS FULLY COMPLETED FORM TO:
[email protected]
Caritas House, Tregony Road
Orpington, Kent BR6 9XA
T 01689 825755 www.stchristophers.org.uk
Version 1 29.09.16