Hernia Surgery Request Letter: Template & Step-by-Step Guide

A well-structured letter to your surgeon ensures clear communication of symptoms, history, and expectations. Below is a customizable template with annotations.

Template

[Your Full Name]
[Your Address]
[City, State, ZIP]
[Email Address]
[Phone Number]
[Date]

[Surgeon's Full Name, MD]
[Practice/Clinic Name]
[Office Address]
[City, State, ZIP]

Subject: Request for Surgical Consultation – [Type] Hernia Repair

Dear Dr. [Last Name],

I am writing to request your expert evaluation for surgical repair of a [inguinal / umbilical / incisional / femoral / hiatal] hernia diagnosed on [date] by [diagnosing provider]. My medical record number is [MRN].

History & Symptoms:
- Onset: [Month/Year] – initially noticed a [small/reducible] bulge in the [specific location: e.g., right groin, midline abdomen].
- Progression: The bulge has become [larger / non-reducible / more prominent] over the past [timeframe].
- Symptoms: [Pain / discomfort / heaviness / burning] worsened by [lifting, standing, coughing, straining, bending]. Current pain level: [/10].
- Impact: Interferes with [work / exercise / sleep / daily activities]. [Missed work days: X].
- Prior management: [Watchful waiting / truss / lifestyle modification / prior surgery (date/type)].

Attached Records:
- Imaging: [Ultrasound / CT / MRI] report dated [date]
- Lab results: [CBC, BMP, coagulation, etc.]
- Prior operative notes (if applicable)
- Referral/authorization forms

Questions for Consultation:
1. Am I a candidate for [open / laparoscopic / robotic] repair? Pros/cons for my case?
2. Mesh vs. non-mesh (tissue) repair – your recommendation?
3. Expected recovery timeline: return to desk work / heavy lifting / exercise?
4. Post-op restrictions, pain protocol, follow-up schedule?
5. Risks specific to my history (obesity, smoking, diabetes, prior mesh, anticoagulation)?
6. Insurance pre-authorization requirements?

I am committed to following all pre- and post-operative instructions to optimize outcomes. Please contact me at [phone/email] to schedule at your earliest convenience.

Thank you for your time and expertise.

Sincerely,
[Your Signature]
[Your Printed Name]

Essential Components Checklist

• ☐ Clear subject line with hernia type
• ☐ Specific location, laterality, duration
• ☐ Symptom triggers and functional impact
• ☐ Relevant imaging/labs attached
• ☐ Specific questions about approach, mesh, recovery, risks
• ☐ Insurance/authorization awareness
• ☐ Contact information and availability

Pro Tips

• Send via patient portal (secure message) for documentation.
• Bring a printed copy to the visit as backup.
• If referred by PCP, include their name and contact.
• Mention any prior mesh reactions or chronic pain syndromes.