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Referral form for East and North Herts Lymphoedema ServicePATIENT NAME: NHS NUMBER:DATE OF BIRTH: TEL.NO:ADDRESS:Ethnic Origin: Religion:Reason for referral:Interpreter required: YES / NO Language spoken: Referred by:Tel: Date of Referral:Address for correspondence:Other services involved (i.e. community nurses/ palliative care etc.)GP Name and Surgery:Past Medical History (including cancer history and treatment details)Current MedicationWeight: Height: BMI:NB: if BMI over 40 the patient must be actively engaged in weight loss before treatment will be offered Send Referral to:Queensway Health ClinicQueenswayHatfieldHertsAL10 0LFE-Mail: herts.lymphoedemaservice@Tel: 01707 252466Before referring please ensure:Adequate medical summary providedNo wounds or ‘leaky legs’BMI less than 40 or on active weight managementIf there is evidence of arterial or venous compromise, DVT, unstable cardiac or renal disease that these have been treated or optimised before referral ................
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