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.

University Surgical Associates USA
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


PDF of Part B-2