Lipodoema Referral Form
REFERRER INFORMATION
Name
First Name
Last Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
PATIENT CONTACT INFORMATION
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Contact Number
Format: (000) 000-0000.
Reason for Referral
Conservative management
Preparation for surgery
Post-surgical management
Management of secondary lymphoedema
Other
Affected Body Part/s
Upper limb
Lower limb
Bilateral lower limb
Head and Neck
Chest/breast wall
Genital
Other
Preferred Treatment Modalities
Manual Lymph Drainage
Pneumatic compression pump
Compression garmenting solutions
Photobiomodulation (low level light therapy/laser)
Other
Referring Doctor's Comments
Signature
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Should be Empty: