Download Colonoscopy Prep Information

GASTROINTESTINAL SPECIALISTS
Aria Torresdale Medical Office Bldg.
3998 Red Lion Rd S.242
Philadelphia, Pa 19114
215-632-3500
Date:__________________________
Barix Clinic
280 Middletown Blvd
Langhorne, Pa 19047
215-702-7090
Date:__________________________
COLONOSCOPY PREP INFORMATION
For all colonoscopy preps, you need to be on a CLEAR LIQUID DIET the entire day before the
procedure. No solid food. This includes clear liquids for breakfast, lunch and dinner
the entire day before the procedure. You must take one of the following bowel cleansing
preparations as indicated.
o
GoLytely: This prep comes in powder form. Mix it with one gallon of water. Refrigerate this solution
early in the morning so that it can chill throughout the day. Start to take the prep at 4:00 p.m. Drink one
8 ounce glass every 20 minutes until the entire contents have been consumed.
o
Osmo Prep:
First Dose: Start at 4:00 p.m. Take 4 Osmo Prep tablets every 15 minutes with at least 8
ounces of clear liquid, and continue until you have taken all 20 tablets.
Do not exceed 20 tablets.
Second Dose: Start at 8:00 p.m. Take 4 Osmo Prep tablets every 15 minutes with at least 8
ounces of clear liquid. Do not exceed 12 tablets.
o
Half-Lytely: Start at 1:00 p.m. Take 2 bisacodyl delayed-release tablets with water. Add lukewarm
drinking water to the top of the line on the bottle. Cap the bottle and shake to dissolve the power.
Refrigerate. Start to drink the solution at 4:00 p.m. - at least 8 ounces every 20 minutes (approximately
8 glasses). Drink each glass quickly.
o
Miralax Prep: Mix 238 grams of Miralax in 64 ounces of Gatorade (not red or purple) early in the day.
Starting at 5:00 p.m. the night before the colonoscopy, drink one 8 ounce glass every 30 minutes.
Additionally, take one (1) Dulcolax tablet before starting the Miralax drink and one (1) Dulcolax tablet
after completion of the Miralax Prep (TOTAL OF ONLY 2 DULCOLAX TABLETS).
o
MoviPrep: Empty one Pouch A and one Pouch B into the disposable container. Add lukewarm
drinking water to the top of line on bottle. Cap the bottle and shake to dissolve the powder.
Refrigerate. Start to drink the solution at 4:00 p.m., at least 8 ounces every 15 minutes (approximately
four glasses) until the bottle is completed. A minimum of an hour and a half later, repeat the entire
process. Drink at least one additional liter of clear liquid during the course of the evening.
Clear liquids in between the prep are unlimited.
Please have nothing to eat or drink after midnight
Failure to comply with these instructions may result in an inadequate bowel cleansing. Inadequate
bowel cleansing prevents visualization of the colon and may cause cancellation and rescheduling of
your procedure.
GASTROINTESTINAL SPECIALISTS
Aria Torresdale Medical Office Bldg.
3998 Red Lion Rd S.242
Philadelphia, Pa 19114
215-632-3500
Barix Clinic
280 Middletown Blvd
Langhorne, Pa 19047
215-702-7090
We attempt to accommodate all of our patients and there are many patients waiting for
a procedure. For this reason, we ask you make every attempt to keep your appointment. If
you are unable to keep your scheduled appointment, please notify our office at least 72 hours
prior to your scheduled procedure.
Patients who fail to present for their scheduled procedure without calling to cancel their
appointment may not be rescheduled.
COLONOSCOPY DAY OF PROCEDURE INSTRUCTIONS
On the morning of your procedure you may take medications for heart conditions and blood
pressure with a SMALL SIP of water.
Diabetic Patients - Please call the office to receive instructions regarding insulin or diabetic
medication.
If you take any blood thinning medication (Aspirin, Ecotrin, Motrin), etc., antiplatelet
(Coumadin, Aggrenox, Plavix) or arthritis medication (Vioxx, Celebrex) please notify your
doctor. These medications must be stopped 5 to 7 days prior to your scheduled procedure.
Please discuss this with your physician and/or cardiologist.
!!!!! IMPORTANT!!!!!
Our policy is that because you will be receiving an anesthetic, it is MANDATORY that a
friend or family member accompanies you home. Please note that if you are unable to
comply with the above your procedure may be cancelled.
*** DO NOT wear any jewelry to your procedure; We are NOT responsible for the loss of any
valuables: earrings, rings watches, etc....
*** Please bring a copy of Advance Directive *(Document detailing your decisions for
healthcare in case of emergency) if you have one to our facility on the day of your procedure.
*** IT IS EXTREMELY IMPORTANT THAT YOU BRING ALL PRESCRIPTION MEDICATION
BOTTLES WITH YOU ON THE DAY OF YOUR PROCEDURE AS WELL AS YOUR INSURANCE
CARDS AND ANY COPAYS/CO-INSURANCES.***
GASTROINTESTINAL SPECIALISTS
Aria Torresdale Medical Office Bldg.
3998 Red Lion Rd S.242
Philadelphia, Pa 19114
215-632-3500
Barix Clinic
280 Middletown Blvd
Langhorne, Pa 19047
215-702-7090
CLEAR LIQUID DIET
This diet provides fluids that leave little residue and are easily
absorbed with minimal digestive activity. This diet is inadequate in all
essential nutrients and is recommended only if clear liquids are
temporarily needed.
NO RED OR PURPLE LIQUIDS SHOULD BE CONSUMED
FOODS ALLOWED:
o Tea (decaffeinated or regular)
o Carbonated beverages - such as 7-UP, Ginger-Ale
o Fruit flavored drinks - such as lemonade, flavored
iced-tea, Gatorade, or flavored water
o Strained fruit juices - apple juice, white grape juice, or
white cranberry juice
o Clear broth or consommé (Chicken, Beef, or
Vegetable)
o Jell-O (no fruit or toppings) (NO RED OR PURPLE)
o Popsicles (NO RED OR PURPLE)
o Water Ice (NO RED OR PURPLE)
GASTROINTESTINAL SPECIALISTS
Aria Torresdale Medical Office Bldg.
3998 Red Lion Rd S.242
Philadelphia, Pa 19114
215-632-3500
Barix Clinic
280 Middletown Blvd
Langhorne, Pa 19047
215-702-7090
IMPORTANT INFORMATION REGARDING YOUR INSURANCE
Dear Patient:
Should your doctor determine that you require a diagnostic endoscopy (upper
endoscopy and/or colonoscopy); your procedure will be performed in the
Gastrointestinal Specialists Ambulatory Surgical Center. The Ambulatory
Surgical Center is approved by Medicare, licensed by the Commonwealth of
Pennsylvania and accredited by the Joint Committee on Accreditation of Health
Care Organizations.
The Ambulatory Surgical Center is an outpatient facility, therefore, your
insurance carrier will be billed a facility fee and any outpatient deductibles and/or
co-pay for your individual insurance plan will apply. If you are uncertain of your
policy deductibles, please contact your insurance carrier for this information.
You will be responsible for the deductible and co-pay. These will be due at time
of service.
For the comfort and safety of patients undergoing endoscopic procedures,
physicians and nurse anesthetists employed through Anesthesia Advantage of
Newtown, PA. provide conscious sedation during the endoscopic procedure.
Anesthesia Advantage will bill your insurance carrier and deductibles and/or copays will apply.
Patients without insurance will be required to make financial arrangements prior
to performance of procedure.
Thank you.
Billing Dept. - Gastrointestinal Specialists, Inc. 610-664-9730 or 9731
Billing Dept. - Anesthesia Advantage 215-860-4110
GASTROINTESTINAL SPECIALISTS
Aria Torresdale Medical Office Bldg.
3998 Red Lion Rd S.242
Philadelphia, Pa 19114
215-632-3500
Barix Clinic
280 Middletown Blvd
Langhorne, Pa 19047
215-702-7090
Patient Name: ____________________________________________
Patient Date of Birth: _______/_______/_______
Date of Procedure: _______/_______/_______
In order to maintain compliance with the Pennsylvania Human
Relations Act of 1955 and Title VI of the Federal Civil Rights Act of
1964, the Ambulatory Surgical Center is asked to prepare
documentation of the following information regarding patient visits.
Answers to the following questions are entirely voluntary on the part
of the patient.
Racial Background: _______________________________________
Religious Preferences: _____________________________________
Decline to Answer: ________________________________________
Patient Signature