Lymphoedema Referral Form Lymphoedema Referral Form | Teesside Hospice

Please complete the below form to make a referral for our Lymphoedema Clinic.

Patient Details

First name

Surname

Likes to be known as (optional)

Occupation

Email address

Phone number

Date of Birth

Address

Town

Postcode

County

Country

Type of Referral

Routine

Urgent

Patient Agreement to Referral

Yes

No

Patient lives alone

Yes

No

Where patient lives

Home

Hospital

Hospital Ward

Main Carer Details

Title

First Name

Surname

Email address

Mobile number

Date of Birth

Address

Town

Postcode

County

Work Tel. Number

Medical Information

NHS No.

Hospital ID Number

Names of consultant(s) invloved

GP Name

Telephone Number

Surgery

Diagnosis

Diagnosis Date (DD/MM/YYY)

Metastasis

Metastasis Date (DD/MM/YYY)

Recurrence

Recurrence Date (DD/MM/YYY)

Previous Treatment

Reason for Referral

History of Onset of Oedema

Main Concern/Issues

Previous Investigations/Treatments

Previous Medical Treatments

Current/Planned Treatments

Current Medication/Allergies

Health & Social Services Involvement

Social Worker/Care Manageer Name

Social Worker/Care Manageer Tel.

Macmillan Nurse Name

Macmillan Nurse Tel.

Specialist Nurse/Community Matron Name

Specialist Nurse/Community Matron Tel.

District Nurse Name

District Nurse Tel.

Other Name

Other Tel.

Referrer Details

Title

First Name

Surname

Date of Referral

Email address

Mobile number

Date of Birth

Address

Town

Postcode

County

Organisation

Department

Job Title

Please send copies of any clinical correspondence with this form

Clinical Correspondence