Download glycolax/gatorade preparation

COLONOSCOPY / EUS (circle one)
GLYCOLAX / GATORADE PREP
*Immediately purchase 4 Dulcolax (Bisacodyl) laxative tablets (non-prescription) in the laxative section of the pharmacy, along
with the 255 gram bottle of Glycolax at your requested pharmacy, and 64 oz. or ½ gallon of Gatorade (NO red or purple)
Name:
Birth Date:
Procedure Date:
Location:
 Oregon Pike Office
 Lancaster Office
Arrival Time:
Patient Acct #:
Physician:
 Lancaster General Health
 Ephrata Community Hospital
 Heart of Lancaster Regional Medical Center  Lancaster Regional Medical Center
MEDICATION INSTRUCTIONS: (Only those checked apply to you)
___Take all your medications as usual (including blood pressure and cardiac)
___Stop Coumadin___days prior to your procedure. Stop taking on______.
___Stop iron or iron-containing medication for ___days prior to your procedure. Stop taking on _______________.
___No NSAIDs (non-steroidal anti-inflammatory drugs) such as Naproxen (Aleve), Ibuprofen (Motrin or Advil), or similar
medications___days prior to your procedure. Stop taking on________________.
___Special diabetic medications instructions: _________________________________________________________________
___Other instructions: ___________________________________________________________________________________
DAY BEFORE PROCEDURE: NO SOLID FOODS FOR ENTIRE DAY, ONLY FULL AND CLEAR LIQUIDS FROM LISTS
BELOW-STARTS FROM THE TIME YOU ARISE.
1. Mix bowel preparation of 255 gm/Glycolax with 64 ounces or ½ gallon of Gatorade (NO red or purple). Refrigerate.
2. Drink a minimum of 128 ounces or one gallon of fluids throughout the day, drawing from both lists below. Drink more if you
can. There is no limit to how much you can drink.
FULL LIQUIDS ALLOWED
Cream, custard, smooth pudding, milk, milkshakes, plain ice cream, plain yogurt, frozen yogurt, sherbert, cream soups
including tomato soup (strain out solids), Slim Fast and/or Ensure. You may have milk in coffee/tea until 6pm.
CLEAR LIQUIDS ALLOWED
Water, coffee or tea without milk, clear fruit juices (apple, white grape, white cranberry), Jell-O without fruit (no red or
purple),Gatorade, Kool Aid, Hi C, Italian Ice, ice pops, sodas (diet or regular), ginger ale, Sprite, 7-Up and broth.
*ALL items must be smooth. Avoid items with seeds or nuts a few days prior. No red or purple items except for tomato soup.
No ALCOHOLIC BEVERAGES.
3. Take the four Dulcolax tablets at 2 PM.
4. At 6 PM, start drinking the prep. Drink an 8 oz. glass every 15 minutes, until you have taken in half of the mixed prep. Drink
each glass quickly. It will take approximately one hour to complete.
5. After drinking the first half of prep, refrigerate the remaining half of prep solution. Continue drinking CLEAR LIQUIDS ONLY
at this time through the evening. Taking in at least 16 more ounces. Drink more if you can.
DAY OF PROCEDURE:
1. At ______ (4 hours before leaving your home), begin drinking the remaining second half of the prep. Drink an 8 oz glass
every 15 minutes until the container is empty. Once finished with the bowel prep, you are to have nothing else by
mouth. NO water, gum, mints, etc. If you do not follow these instructions, you are at risk for having your procedure
cancelled.
Please call RGAL at 717-544-3400 or visit our website www.RGAL.com for frequently asked questions.
Reviewed by: ____________________________________________
Print Name
2104 HARRISBURG PIKE, SUITE 300  PO BOX 3200  LANCASTER, PA 17604-3200
4140 OREGON PIKE  EPHRATA, PA 17522
(717) 544-3400  FAX (717) 544-3408
www.RGAL.com
0037E Rev 10/2013