Your Name*Date* Address*Diagnosis*Past Medical History Cancer Arterial Insufficiency CCF or unstable cardiac conditions Venous insufficiency Peripheral Neuropathy Cancer TypeLymphoedema or Scar History(if condition is basis of referral)Details/Date of onsetAffected areasCurrent/previous treatmentTreating Medical PractitionerNameDesignationProvider NoDate PhoneReferrer*if different to treating medical practitionerNameDesignationProvider NoDate Phone
