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City & Hackney lymphoedema referral

To make your City & Hackney lymphoedema referral please complete all the applicable fields in the form below.

Please ensure all housebound patients are seen in the first instance by Community Services in advance of referral to the Lymphoedema Clinic.

Speak to our team

We can help with any referral questions you may have.

Give us a call on 020 3819 6022

City & Hackney Lymphoedema referral form

Referral date*
Full name of patient*
Patient's title*
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 phone number*
Patient's mobile number (optional)
Patient's email (optional)
Patient's ethnicity*
Translation needed?*
- Yes
- No
Language for translation
Next of kin / carer name
Next of kin / carer telephone number
Referral made by?*
Referrer job title*
Referrer phone number*
Referrer email address*
GP name*
GP practice*
GP address*
Street Address Address Line 2 City Post code
GP phone number*
GP email*
District Nurse or Practice Nurse (name / team)*
Address*
Street Address Address Line 2 City Post code
Nurse phone number*
Nurse email*
Referral criteria met*
- Recurrent cellulitis
- Lymphorrhoea (leaky legs)
- Known to Adult Community Nursing Service for chronic oedema / lymphoedema
- Lymphoedema secondary to cancer
- Primary lymphoedema
Reason for lymphoedema referral*
Areas affected*
Approximate date of onset
Skin description eg intact; leaking; recent cellulitis
Please include specific dates in relation to Lymphorrhoea (Leaky Legs) and Cellulitis*
Current medication, please state if none*
Known allergies, please state if none*
Cancer diagnosis (including dates)
Details of any surgery including dates
Details of any chemotherapy including dates
Details of any radiotherapy including dates
Please tick if the patient has, or has had, any of the following*
- Heart failure
- Renal disease
- Thyroid disease
- Vascular disease
- Deep vein thrombosis
- Chronic skin disorder
- Diabetes
- Rheumatoid arthritis
- Low serum protein/albumin
- None of the above
Any other details
Mobility status*
- Fully mobile
- Mobility aid
- Housebound
If housebound the patient MUST be known to the Community Nursing Service. Please confirm by ticking the box*
Housebound is defined as a person being unable to attend the clinic independently and safely.
- Yes
Any other comments about mobility
Upload your patient's EMIS history
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.
Confirm EMIS print out of history emailed to acceleratecic.accelerate@nhs.net OR uploaded above*
- Confirm
If you want to provide photographs of a wound or limb, email them securely to acceleratecic.accelerate@nhs.net giving the name of the patient and date of birth.
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Together we’re transforming wound and lymphoedema care.
Discover how we can help you hello@acceleratecic.com

Where to find us

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

T 020 3819 6022

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