2Patient Information Forms

Open each form by first clicking on the link, then print.

Please print and complete the pages on the right, before you arrive for your medical appointment. Bring these forms, filled out, with your identification and insurance card (if applicable).

Dr. Domingo E. Galliano Jr.
MD, FACS, FASCRS

University Surgical Associates USA
GALLIANOSURGERY.COM
18308 Murdock Circle, Suite 108
Port Charlotte, Florida 33948

941.625.3411 VOICE
941.625.1792 FAX

Maps to our office here.


Minimally Invasive Procedures

Experience less pain, minimal scarring, faster recovery, and better results.


Robotic Surgery
via Da Vinci


Laparoscopic Surgery


TEM Transanal Endoscopic Microsurgery


NOSCAR/ NOTES Painless Natural Orifice Trans-endoscopic Surgery


Solesta is a sterile gel injected into the anus to treat the symptoms of fecal incontinence.


Esophyx long-term incisionless solution for chronic acid reflux GERD


STARR Staple Transanal Rectal Resection


ENTERRA -- Gastric Electrical Stimulation for Gatroparesis


Barrx - Radiofrequency Ablation in Barrett's Esophagus with Dysplasia


TIF Transoral Incisionless Fundoplication procedure corrects the root cause of GERD


ABS - Artificial Bowel Sphincter


SECCA - for incontinence


Sacral Nerve Stimulation


Anorectoplasty for anal incontinence


Pelvic rehabilitation for incontinence and constipation, anal / pelvic pain


Anal Fistula Plug


 

Please download and complete these forms and bring with you to your appointment.

 


PDF of Part A

file info


PDF of Part B-1

PIF-1


PDF of Part B-2

pif-2