Referral Form

Before making a referral, please ensure that you have read all of the relevant referral information. You can find it here.

Patient Referral Form
To be completed by Healthcare Professionals only.

Please complete the referral form in its entirety. Incomplete forms will be returned, delaying the referral process.

Please note, when we contact you after receiving your referral, we may ask for additional information in support of your referral.
Patient details
Name*
Prefix
First
Last
Address*
Street Address
City

Postcode
Date of birth*
NHS Number*
Patient telephone number*
Please include this if the patient is to be the first point of contact.
If the patient is to be the first point of contact, are we able to leave voicemail messages on the above phone number if necessary?
- Yes
- No
Next of kin details
Name*
First
Last
Relationship to patient*
Address if known
Street Address
City

Postcode
Telephone number*
If the next of kin is to be the first point of contact, are we able to leave voicemail messages on the above phone number if necessary?
- Yes
- No
GP details
GP Name*
Practice address*
Street Address
City

Postcode
GP telephone number*
Referral to Compton Care
Does the patient agree to this referral?*
- Yes
- No
If 'no', please do not continue with the referral process. Call our team of Medical Secretaries for further advice and information on 0300 323 0250.
What is the reason for referral to Compton Care?
Please select all that apply*
- Care in the home
- Inpatient care
- Day therapies
- Lymphoedema
- Physiotherapy
If your referral is regarding physiotherapy, please ensure that you have read the relevant referral criteria here.
What is the main reason for referral?*
Patient diagnosis*
Please refrain from using any abreviations or jargon.
Other significant medical conditions
Please make us aware of any other significant medical conditions.
Estimated prognosis if known
Additional information
Please inform us of any additional information about the patients condition.
Is the patient in hospital?*
- Yes
- No
Name of hospital
Hospital ward
Patient hospital number
Please note, this should be the hospital number given to the patient, and not a telephone number
Name of consultant
Planned discharge date (if known).
Day Therapies Risk Assessment
Can the patient get to the Day Therapies Centre via their own transport?
- Yes
- No
- Not Assessed
Can the patient walk from their house to a vehicle?
- Yes
- No
- Not applicable
- Not assessed
Independent in wheelchair
- Yes
- No
- Not applicable
- Not assessed
Electric wheelchair
- Yes
- No
- Not applicable
- Not assessed
Can the patient get in and out of the wheel chair independently?
- Yes
- No
- Not assessed
Is there space available at the patients location for transport to pick up and drop off the patient?
- Yes
- No
- Not assessed
Is the patient able to get in and out of the front doors of a car?
- Yes
- No
- Not assessed
Is the patient able to get in and out of the back doors of a car?
- Yes
- No
- Not assessed
Do you have a Seat Belt Exemption Certificate?
- Yes
- No
- Not assessed
Is there a steep slop to the house?
- Yes
- No
- Not assessed
Please add any other concerns and risks:
Lymphoedema Referral Information
General Medical History
Please complete the following. Has/does the patient suffer/suffered from any of the below conditions:
Hypertension*
- Yes
- No
- Not known
- Controlled
Heart failure*
- Yes
- No
- Not known
- Controlled
Hemiplegia*
- Yes
- No
- Not known
- Controlled
Peripheral vascular disease/Arterial embolism*
- Yes
- No
- Not known
- Controlled
Phlebitis*
- Yes
- No
- Not known
- Controlled
Venous Thrombosis*
- Yes
- No
- Not known
- Controlled
Date and region
Varicose veins*
- Yes
- No
- Not known
- Controlled
Chronic renal failure*
- Yes
- No
- Not known
- Controlled
Chronic skin disorders*
- Yes
- No
- Not known
- Controlled
Rheumatoid Arthritis*
- Yes
- No
- Not known
- Controlled
Osteo-arthritis*
- Yes
- No
- Not known
- Controlled
Diabetes*
- Yes
- No
- Not known
- Controlled
Obesity*
- Yes
- No
- Not known
- Controlled
Thyroid*
- Yes
- No
- Not known
- Controlled
Allergies*
- Yes
- No
- Not known
- Controlled
Other inc surgery/childhood illness*
- Yes
- No
- Not known
- Controlled
Please specify
Please give details of any surgical interventions
Please give your opinion on the cardiac status (is compression therapy contra-indicated?)*
Weight*
Height*
BMI*
BMI > 40: Please ensure actively losing weight
Dietician referral made
- Yes
- No
Please list current medication*
Lymphoedema History
When did the Lymphoedema commence?*
Please detail any past treatment that you have received
Oedema evident in: (please tick all appropriate)*
- Face
- Arm(s)
- Chest
- Abdomen
- Genitals
- Legs
- Other
Do you consider the Oedema as:*
- Mild
- Moderate
- Severe
- Palliative
Is the patient complaining of pain?*
- Yes
- No
Site of pain
Are any of the following skin conditions present?
- Lymphorroea
- Hyperkeratosis
- Intact
- Ulcerated
Other skin changes, please state:
Please describe the patients mobility*
- Independent
- Wheelchair bound
- Housebound
- Other
If other, please specify
If Lymphoedema secondary to cancer, please include copies of correspondence regarding diagnosis, lymph node involvement, treatment received and treatment planned.
Drop files here or
Comments
Referrer name*
First
Last
File
Please include any relevant copy letters from any consultants, along with a copy of the results of blood for U and Es, Thyroid functions and FBC's.
Drop files here or
Please tick to confirm that you have included all of the following:*
Blood results
Cardiac status
Relevant correspondence
Further information
Does the patient have any mobility problems?*
Yes
No
If 'yes', please give detail.
Does the patient have any mental capacity issues?*
Yes
No
If 'yes', please give detail.
Does the patient have any communications issues?*
Yes
No
If 'yes', please give detail.
Does the patient speak a first language other than English?*
Yes
No
If 'yes' please state language
Is a translator needed?
Yes
No
Are there any known risks involved in visiting the patient at home?*
Yes
No
If 'yes', please give details.
Additional information
Please upload any additional information that you feel would be beneficial to Compton Care.
This could include any relevant letters, discharge summaries and scan and blood results.
Drop files here or
Referrer information
Name of referrer*
Job title*
Telephone number*
Email*
Date of referral*
If your referral is urgent, please speak to us via the medical secretaries team on 0300 323 0250 between 8:30am and 4:30pm, or for out of hours enquiries, please ask for the nurse specialist on call.
Please note, the details submitted on the above form will not be discussed with any persons outside of Compton Care without consent.