MoviPrep Colonoscopy Prep (Split dosing) Tanya Davis, M.D. and Ashita Shah, P.A.-C
Patient’s Name__________________ Date________Time_______Location_______________ *There is a $150 fee for procedures cancelled with less than 72 hrs notice.
MoviPrep and Reglan need to be filled at the pharmacy. Dulcolax laxative tablets are an over-the-counter item.
Four days before the procedure:
STOP TAKING iron, anti-inflammatory medication [Ibuprofen, Advil, Motrin.], aspirin, Coumadin,
Plavix, Ginkgo biloba, or other blood thinners 4 days before the procedure.
STOP EATING corn, peas, lettuce, celery, green leafy vegetables, broccoli, raw tomatoes or seeds
4 days before the procedure (tomato paste is ok.)
Two days before the procedure:
Take 2 Dulcolax Laxative tablets in the evening
One day before the procedure (Prep Day): Begin a clear liquid diet. This includes coffee/tea (no milk or non dairy creamer), any soda/seltzer water, apple juice, white grape juice, white cranberry juice without pulp, chicken broth/bouillon soup, yellow Jell-O without fruit, yellow popsicles, Italian ice, clear or lemon Gatorade, Power Ade. No solid food, dairy or anything red or purple in color.
1. Morning: mix one pouch A and one pouch B into the disposable container with lukewarm water. Cap the
bottle, mix to dissolve and refrigerate the solution.
2. 5:30 pm: take the Reglan (metoclopramide) tablet. 3. 6:00 pm: begin drinking the solution. Drink 8oz every 15 minutes until the solution is gone. This should
take approximately 1 hour. Continue the clear liquid diet until midnight.
4. Evening: mix your second container of prep and refrigerate.
The day of the procedure (Procedure Day):
1. Morning: you will be waking up at ____ am to finish the 2nd canister of MoviPrep. You must drink the
entire container 4 hrs before your procedure time.
Note: you may not have any liquids, other than the prep, the morning of your procedure UNLESS your procedure is after 1 pm. Then you may have 2 glasses of clear liquid that morning before 9am. If you take diabetic medications, do not take them the night before or the morning of the procedure. You MAY take your other medications, especially your blood pressure medication, with a small sip of water the morning of the procedure. *Please bring all your medications, including inhalers to the procedures. If you use a BiPap or CPAP machine at home, please bring those as well. Please, do not use any lotion on your skin the day of the procedure.
You must have someone drive you home from the procedure. You cannot take Taxi home. If you have a procedure done at INOVA Healthplex: report directly to the 2nd floor Surgical Suite 45 minutes before your scheduled procedure time. If you have a procedure done at Mount Vernon Hospital: report directly to Same Day Surgery Suite (Yellow Parking entrance) on the first floor 60 minutes before your scheduled procedure time. If you have a procedure done at Digestive Healthcare Endoscopy Suite: report to suite 307 at 2616 Sherwood Hall Drive in the Sherwood Hall Medical Center 30 minutes before your scheduled procedure time. You may bring a robe and slippers for your comfort (Digestive Healthcare Endoscopy suite patients only)
Call the office for questions or problems with the prep at 703 780-7010. 2/1/2013
DAkkS Deutsche Akkreditierungsstelle GmbH Appendix to Accreditation Certificate D-PL-14082-01-00 According to DIN EN ISO/IEC 17025:2005 Validity: 10 June 2010 to 17 July 2013 Holder of certificate: LUFA-ITL GmbH Dr.-Hell-Straße 6, 24107 Kiel, Germany Testing and analysis in the fields of: Physical, physical-chemical, chemical and microbiological analyses of water, waste water, groundwater, surfa
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