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Lymphoedema Clinic referral

If you need any help using our online referral system, please call the Referrals Team on
0191 529 7100

This page is for healthcare professionals to make patient referrals. The quickest and easiest way to make a referral is to use our online referral forms. However, if you would prefer to print off a form and send it to us by post or fax, you can download them using the links on each service listing below.

Online referral form

Patient Details

General Medical History

Please delete as appropriate if the named patient suffers from or has experienced any of the following:-

Chronic Renal Failure -

Yes No

Chronic Skin Disorders -

Yes No

Diabetes -

Yes No

Heart Failure -

Yes No

Hemiplegia -

Yes No

Obesity -

Yes No

Osteo-arthritis -

Yes No

Peripheral Vascular Disease/ Arterial Embolism -

Yes No

Phlebitis -

Yes No

Rheumatoid Arthritis -

Yes No

Varicose Veins -

Yes No

Venous Thrombosis -

Yes No

Lymphoedema Secondary to Cancer:

Please complete if appropriate to this patient:

Complications of cancer:

Regional Lymphnode involvement

Yes No

Regional skin involvement

Yes No

Local Recurrence

Yes No

Distant Metastases

Yes No

Treatment and Dates:

Any contra-indications to any aspects of Lymphoedema Treatment? Yes No
Any objections to any aspect of Lymphoedema Treatment? Yes No