---
title: Primary Care to Lymphedema Therapy Referral Form Template | Paperform
description: Comprehensive lymphedema therapy referral form for primary care providers. Includes extremity swelling assessment, cancer treatment history, compression garment evaluation, and manual lymphatic drainage screening.
url: "https://paperform.co/templates/primary-care-to-lymphedema-therapy-referral-form"
type: static
generatedAt: "2026-03-28T00:44:53.175Z"
---

[← Back to free form templates](/templates/)    ![Primary Care to Lymphedema Therapy Referral Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/primary-care-to-lymphedema-therapy-referral-form.png)
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### Streamline Lymphedema Therapy Referrals with Paperform

When primary care physicians identify patients with extremity swelling or lymphedema, timely referral to specialized lymphedema therapists is critical for effective management and quality of life. This **Primary Care to Lymphedema Therapy Referral Form** template provides a comprehensive, structured approach to gathering essential patient information, swelling assessments, cancer treatment history, and therapy candidacy details—all in one professional, easy-to-complete form.

#### Why Use This Lymphedema Referral Form Template?

Lymphedema therapy requires detailed clinical information to ensure appropriate treatment planning. Traditional paper referrals or scattered fax communications often lead to incomplete information, delays in care, and back-and-forth between providers. This Paperform template solves those problems by:

 - **Capturing complete clinical history** including cancer treatment, surgeries, and radiation that may contribute to lymphedema
 - **Documenting precise swelling assessments** with location, severity, and onset details
 - **Evaluating compression therapy needs** and previous interventions
 - **Assessing candidacy for manual lymphatic drainage** and specialized treatments
 - **Ensuring faster specialist intake** with all necessary information provided upfront

#### Perfect for Primary Care Providers, Oncologists, and Medical Practices

This form template is designed for healthcare providers who regularly refer patients for lymphedema therapy, including:

 - **Primary care physicians** managing patients with chronic swelling or post-surgical complications
 - **Oncology practices** referring cancer survivors with treatment-related lymphedema
 - **Vascular specialists** identifying patients who need comprehensive lymphedema management
 - **Surgical practices** following up on post-operative swelling complications
 - **Hospital systems** streamlining referral workflows between departments

#### Key Features of This Lymphedema Referral Template

The form is thoughtfully organized into logical sections that mirror the clinical assessment process:

**Patient and Referring Provider Information** – Capture complete contact details, insurance information, and referring physician credentials for seamless communication and billing.

**Medical History and Lymphedema Background** – Document cancer diagnosis history, surgical procedures, radiation therapy, and other risk factors that contribute to lymphedema development.

**Extremity Swelling Assessment** – Detailed evaluation of affected limbs, swelling severity, onset timeline, and progression patterns that inform treatment approaches.

**Current Symptoms and Functional Impact** – Understanding how lymphedema affects daily activities, mobility, and quality of life helps therapists prioritize treatment goals.

**Compression Therapy History** – Record previous compression garment use, patient tolerance, and effectiveness to guide future recommendations.

**Manual Lymphatic Drainage Candidacy** – Screen for contraindications and assess suitability for specialized manual therapy techniques.

**Clinical Measurements and Documentation** – Space for limb circumference measurements, tissue consistency notes, and other objective findings.

#### Automate Your Healthcare Referral Workflow with Stepper

Once a lymphedema referral is submitted through Paperform, you can use [Stepper](https://stepper.io) to automate what happens next. Create workflows that:

 - Automatically send referral notifications to the lymphedema therapy team
 - Route urgent cases based on swelling severity or cancer treatment timeline
 - Create patient records in your practice management or EHR system
 - Schedule follow-up calls or appointments with the specialty clinic
 - Send confirmation emails to both the referring provider and patient
 - Generate referral summary PDFs for medical records

This automation reduces administrative burden on your medical staff while ensuring no referral falls through the cracks.

#### HIPAA Considerations and Healthcare Compliance

While Paperform offers SOC 2 Type II compliance and robust security features suitable for many healthcare workflows, it's important to note that **Paperform is not a HIPAA-compliant solution**. For practices that require full HIPAA compliance when collecting protected health information (PHI), you may need to:

 - Use this template for internal referral coordination within your existing compliant systems
 - Collect only the minimum necessary information for referral purposes
 - Implement additional safeguards and business associate agreements with your complete technology stack
 - Consult with your compliance team about appropriate use cases

For practices with less stringent requirements or those handling referral coordination that doesn't involve highly sensitive PHI, Paperform provides an excellent balance of security, usability, and workflow automation.

#### Designed for Efficiency and Clinical Accuracy

This template balances thoroughness with practical completion time. Conditional logic shows only relevant questions based on previous answers—for example, detailed cancer treatment history questions only appear if the patient has a cancer diagnosis. This intelligent branching keeps the form concise while ensuring specialists receive complete information for accurate treatment planning.

The form works beautifully across all devices, so referring providers can complete referrals from their desktop workstations, tablets during patient visits, or even smartphones when reviewing cases remotely. The clean, professional design reflects well on your practice and provides a smooth experience for busy healthcare providers.

#### Customize to Match Your Practice Workflow

Every medical practice has unique referral requirements and specialty provider relationships. This template is fully customizable in Paperform's intuitive editor:

 - Add your practice logo and brand colors for professional consistency
 - Include specific insurance requirements or pre-authorization fields
 - Adjust swelling assessment scales to match your clinical protocols
 - Add fields for specialized imaging or diagnostic test results
 - Customize confirmation messages with your specific referral timeline and next steps
 - Integrate with your existing practice management software

#### Better Referrals Mean Better Patient Outcomes

Lymphedema is a chronic condition that significantly impacts quality of life, but early intervention and appropriate therapy can dramatically improve outcomes. By providing lymphedema specialists with comprehensive, well-organized referral information from the start, you're helping ensure your patients receive optimal care without unnecessary delays.

This template helps you maintain the high standard of coordinated care your patients deserve while reducing the administrative complexity of specialty referrals. Start using this Paperform template today and experience smoother referral workflows, better specialist communication, and ultimately, improved patient outcomes in lymphedema management.
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