Skip to main content

01472 350908
Contact Us

Andy's at St Andrew's Hospice

Supporting You
Who We Are
Supporting Us
Join Us
Our Shops

Referrals Donate now

Supporting You
Who We Are
Supporting Us
Join Us
Our Shops

Supporting You
Who We Are
Supporting Us
Join Us
Our Shops

Supporting You
Who We Are
Supporting Us
Join Us
Our Shops

Referrals Donate now

Lymphoedema Referral Form

Supporting You
I'm a professional

Lymphoedema Referral Form - Section 1 of 4
Your Name
Your Email
Patient Details
Patient Name

First Name
Last Name
NHS Number
Date of Birth
Day - Month - Year
Sex

Address

Street Address
Street Address 2
City	Region
Postal Code	Country

Home Phone
Area CodePhone Number
Mobile
Area CodePhone Number
Email

Lymphoedema Referral Form - Section 2 of 4
Referral Information
Date of Referral
Day - Month - Year
Referred By
Name of Person Referring
Name of GP Practice
Name of GP
GP Telephone Number
Area CodePhone Number
GP Email Address
Name of Consultant
Consultant Telephone Number
Area CodePhone Number
Consultant Email Address
Past Medical History
Medication List

Lymphoedema Referral Form - Section 3 of 4
Lymphoedema History
Date Lymphodema noted
Day - Month - Year
Do you consider the Lymphoedema as:

Bilateral Mild Moderate Severe Palliative
Past Treatment
IF LYMPHOEDEMA SECONDARY TO CANCER
Cancer Diagnosis Date
Day - Month - Year
Cancer Treatment Days

Monday Wednesday
Friday Sunday
Tuesday Thursday
Saturday
Positive Lymph Node Dissection?

Yes
No
Metastasis to Lymph Node?

Yes
No
Regional Skin Involvement

Yes
No
Local Recurrence

Yes
No
Distant Metastasis

Yes
No
Removal Lymph Nodes: Level 1

Yes
No
Removal Lymph Nodes: Level 2

Yes
No
Removal Lymph Nodes: Clearance

Yes
No
Surgery
Radiotherapy
Chemotherapy
Hormone Therapy
Other

Lymphoedema Referral Form - Section 4 of 4
General Medical History
Hypertension

Yes
No
Heart Failure

Yes
No
Hemiplegia

Yes
No
Peripheral Vascular Disease/ Arterial Embolism

Yes
No
Phlebitis

Yes
No
Venous Thrombosis

Yes
No
Varicose Veins

Yes
No
Chronic Renal Failure

Yes
No
Chronic Skin Disorders

Yes
No
Rheumatoid Arthritis

Yes
No
Osteo-Arthritis

Yes
No
Diabetes

Yes
No
Obesity

Yes
No
Thyroid

Yes
No
Allergies

Yes
No
Is the patient mobile?

Yes
No
Other
Details
For enquiries telephone: 01472 571277
Captcha

Contact Us

01472 350908
hello@standrewshospice.com

Peaks Lane
Grimsby
DN32 9RP

Charity Information

Accessibility
Feedback
Terms and Conditions
Privacy Policy
Cookies

CQC - Rated Good

Quick Links

Refer
Donate
Jobs
Fundraise
Shops

Copyright © 2026 St Andrew’s Hospice.
St Andrew’s Hospice (Trading) Ltd is a company registered in England and Wales and Limited by Guarantee no 02775647, VAT number 911 3025 78.

Built by Purple Creative Studio