SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
Schedule 13G
(Rule 13d-102)
INFORMATION STATEMENT PURSUANT TO RULES 13d-1 AND 13d-2
UNDER THE SECURITIES EXCHANGE ACT OF 1934
(Amendment No._______)*
General Surgical Innovations, Inc.
- --------------------------------------------------------------------------------
(Name of Issuer)
Common Stock
- --------------------------------------------------------------------------------
(Title of Class of Securities)
0003710131
- --------------------------------------------------------------------------------
(CUSIP Number)
*The remainder of this cover page shall be filled out for a reporting person's
initial filing on this form with respect to the subject class of securities, and
for any subsequent amendment containing information which would alter
disclosures provided in a prior cover page.
The information required on the remainder of this cover page shall not be deemed
to be "filed" for the purpose of Section 18 of the Securities Exchange Act of
1934 ("Act") or otherwise subject to the liabilities of that section of the Act
but shall be subject to all other provisions of the Act (however, see the
Notes).
(Continued on following pages)
Page 1 of 6 Pages
<PAGE>
- ------------------------------ -----------------------------
CUSIP NO. 0003710131 13 G Page 2 of 6 Pages
- ------------------------------ -----------------------------
- --------------------------------------------------------------------------------
1 NAME OF REPORTING PERSONS
SS OR I.R.S. IDENTIFICATION NO. OF ABOVE PERSONS
Thomas Fogarty, M.D. ("Fogarty")
Tax ID Number:
- --------------------------------------------------------------------------------
2 CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP*
(a) [ ] (b) [x]
- --------------------------------------------------------------------------------
3 SEC USE ONLY
- --------------------------------------------------------------------------------
4 CITIZENSHIP OR PLACE OF ORGANIZATION
U.S. Citizen
- --------------------------------------------------------------------------------
NUMBER OF SHARES 5 SOLE VOTING POWER
BENEFICIALLY 1,860,013 shares, of which 27,454
OWNED BY EACH are shares issuable upon exercise
REPORTING PERSON of a stock option.
WITH ---------------------------------------------
6 SHARED VOTING POWER
256,270 shares, of which 209,184
are directly owned by Three Arch
Partners, L.P.("TAP") and 47,086
are directly owned by Three Arch
Associates, L.P. ("TAA"). Fogarty
is a general partner of Three Arch
Management Partners, L.P. ("TAM"),
the general partner of TAP and TAA,
and may be deemed to have shared
power to vote these shares.
---------------------------------------------
7 SOLE DISPOSITIVE POWER
1,860,013 shares, of which 27,454
are shares issuable upon exercise
of a stock option.
---------------------------------------------
8 SHARED DISPOSITIVE POWER
256,270 shares, of which 209,184
are directly owned by TAP and
47,086 are directly owned by TAA.
Fogarty is a general partner of
TAM, the general partner of TAP and
TAA, and may be deemed to have
shared power to dispose of these
shares.
- --------------------------------------------------------------------------------
9 AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH
REPORTING PERSON 2,116,283
- --------------------------------------------------------------------------------
10 CHECK BOX IF THE AGGREGATE AMOUNT IN ROW (9)
EXCLUDES CERTAIN SHARES* [ ]
- --------------------------------------------------------------------------------
11 PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW 9
16.04%
- --------------------------------------------------------------------------------
12 TYPE OF REPORTING PERSON*
IN
- --------------------------------------------------------------------------------
* SEE INSTRUCTIONS BEFORE FILLING OUT!
<PAGE>
Page 3 of 6 Pages
ITEM 1(a). NAME OF ISSUER:
---------------
General Surgical Innovations, Inc.
ITEM 1(b). ADDRESS OF ISSUER'S PRINCIPAL EXECUTIVE OFFICES:
------------------------------------------------
3172-A Porter Drive
Palo Alto, CA 94304
ITEM 2(a). NAME OF PERSONS FILING:
-----------------------
This Statement is filed by Thomas Fogarty, M.D. ("Fogarty").
The foregoing individual is referred to as the "Reporting
Person").
ITEM 2(b). ADDRESS OF PRINCIPAL BUSINESS OFFICE, OR, IF NONE, RESIDENCE:
-------------------------------------------------------------
The address of the principal business office for the Reporting
Person is:
Three Arch Partners
2800 Sand Hill Road, Suite 270
Menlo Park, CA 94025
ITEM 2(c) CITIZENSHIP:
------------
Fogarty is a United States citizen.
ITEM 2(d). TITLE OF CLASS OF SECURITIES:
-----------------------------
Common Stock
ITEM 2(e). CUSIP NUMBER:
-------------
CUSIP # 0003710131
ITEM 3. Not Applicable
--------------
<PAGE>
Page 4 of 6 Pages
ITEM 4. OWNERSHIP:
----------
The following information with respect to the ownership of the
Common Stock of the issuer by the person filing this Statement
is provided as of December 31, 1996:
(a) Amount beneficially owned:
--------------------------
See Row 9 of cover page for the Reporting
Person.
(b) Percent of Class:
-----------------
See Row 11 of cover page for the Reporting
Person.
(c) Number of shares as to which such person
--------------------------------------------
has:
----
(i) Sole power to vote or to
--------------------------
direct the vote:
----------------
See Row 5 of cover page
for the Reporting Person.
(ii) Shared power to vote or to
--------------------------
direct the vote:
----------------
See Row 6 of cover page
for the Reporting Person.
(iii) Sole power to dispose or
--------------------------
to direct the disposition
--------------------------
of:
---
See Row 7 of cover page
for the Reporting Person.
(iv) Shared power to dispose or
--------------------------
to direct the disposition
--------------------------
of:
---
See Row 8 of cover page
for the Reporting Person.
<PAGE>
Page 5 of 6 Pages
ITEM 5. OWNERSHIP OF FIVE PERCENT OR LESS OF A CLASS:
---------------------------------------------
Not applicable.
ITEM 6.
OWNERSHIP OF MORE THAN FIVE PERCENT ON BEHALF OF ANOTHER
--------------------------------------------------------------
PERSON:
-------
Under certain circumstances set forth in the limited
partnership agreements of TAP, TAA and TAM, the general and
limited partners of each of such entities may be deemed to
have the right to receive dividends from, or the proceeds
from, the sale of shares of the issuer owned by each such
entity of which they are a partner.
ITEM 7. IDENTIFICATION AND CLASSIFICATION OF THE SUBSIDIARY WHICH
--------------------------------------------------------------
ACQUIRED THE SECURITY BEING REPORTED ON BY THE PARENT HOLDING
--------------------------------------------------------------
COMPANY:
--------
Not applicable.
ITEM 8. IDENTIFICATION AND CLASSIFICATION OF MEMBERS OF THE GROUP:
----------------------------------------------------------
Not applicable
ITEM 9. NOTICE OF DISSOLUTION OF GROUP:
-------------------------------
Not applicable
ITEM 10. CERTIFICATION:
--------------
Not applicable
<PAGE>
Page 6 of 6 Pages
SIGNATURES
----------
After reasonable inquiry and to the best of my knowledge and
belief, I certify that the information set forth in this statement is true,
complete and correct.
Dated: February 12, 1997
/s/ Thomas Fogarty, M.D.
----------------------------------------
Thomas Fogarty, M.D.
