Patient Contact Form - Lymphoedema & Lipoedema Clinic Nurse Specialist Name * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone (###) ### #### Referral Information * Do you have a referral? Yes No Medical History Have you been diagnosed with (tick all that apply): Lymphoedema Lipoedema Other (please specify) Message Thank you for your inquiry. Our Clinical Nurse Specialist Lymphoedema and Lipoedema will be in contact with you within 2 weeks.
