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Microsoft word - prep_colonoscopy-dulcolax-20120117.docx

PHONE: 910-235-3177
Appointment Date: ___________________ Arrival Time: ___________
Location: _____________________ Physician: ________________
Special Medication Instructions
If you take any blood thinners such as Coumadin, Plavix, Effient, or Pradaxa and you did not see one
of our GI providers in clinic, please contact our office immediately. You will need special instructions
concerning these medications.

Diabetic Patients: DO NOT TAKE
oral diabetic medications or short acting insulin the day before your
procedure. If you normally take long acting insulin in the evening, check your blood sugar. If your blood
sugar is above 100, take ½ your normal dose of long acting insulin. DO NOT TAKE any diabetic
medications the morning of your procedure. Please contact our office and speak with a nurse if you have
questions concerning your diabetic medications during this period of time.
One Week Prior to Your Colonoscopy
Stop taking Iron tablets. This does not include multivitamins.
No foods with Olestra listed an as ingredient (WOW Chips, etc.)
Three Days Prior to Your Colonoscopy
You will need to avoid fruits and vegetables with seeds and skins such as tomatoes and grapes, roughage
foods such as leafy green vegetables or salads, and all beans, corn, and nuts. You may eat MEAT,
*Please Note: In preparation for your procedure, you will need to purchase Dulcolax 5mg
laxative tablets (NOT STOOL SOFTNERS) and orange juice. You will need a total of 12
tablets to complete the prep. These are available over the counter. Each dose should be taken
with 16 oz. of orange juice to avoid potassium loss.
The Day Before the Colonoscopy
Drink only clear liquids for breakfast, lunch, and dinner. No solid foods allowed. Avoid dairy
products or anything red or purple.

Clear liquid list
Water or seltzer, tea or black coffee NO milk or non-dairy creamer. You may have sugar or sugar substitute.
Soft Drinks -Regular or diet sodas (orange, ginger ale, cola, Sprite, 7-Up, etc)
Sports drinks or clear-colored fruit drinks without pulp - Gatorade, Crystal Light, apple juice, etc.
Broths - chicken, beef, or vegetable (without any solid food such as meat, noodles, rice, or vegetables)
Desserts - Jell-O (lemon, lime, orange; no fruit or toppings), popsicles, Italian ice

At 12 noon:
Take 4 Dulcolax 5mg laxative tablets with 16 oz. of orange juice.
At 4pm: Take 4 Dulcolax 5mg laxative tablets with 16 oz. of orange juice.
At 8pm: Take 4 Dulcolax 5mg laxative tablets with 16 oz of orange juice.
It very important that you drink the entire 16 oz. of orange juice with each dose of dulcolax
to avoid potassium loss.

The Morning of Your Procedure

You may drink clear liquids up to 3 hours before your procedure. Then nothing by mouth. It is very
important you follow these instructions or you run the risk of vomiting and aspirating stomach contents into
your lungs.
You May Take the Following Medications with a small sip of water before your procedure: Blood Pressure, Heart, Asthma, Breathing, Seizure, Anti-Depressants, and Thyroid Medications ADDITIONAL INSTRUCTIONS:
1. Bring a list of your medications with the dosages to your procedure appointment. 2. Please bring a Photo ID and your insurance card(s). 3. Wear comfortable clothes that are easy to get into and out of. You may want to wear or bring socks. 4. Your driver may want to bring a drink and/ or snacks. We do not have snack machines in the waiting 5. Do not wear fingernail polish 6. Do not wear necklaces, chains, bracelets, or earrings. You may wear your wedding band and a watch. 7. Please remove nose and/or tongue piercings prior to your procedure. YOU MUST HAVE A RESPONSIBLE DRIVER ACCOMPANY YOU!
The Driver must stay in the waiting area. Patients cannot be dropped off and picked up later. Procedures will be delayed until the designated driver is in the waiting room. What To Expect Prior To Your Appointment
1. You will receive an automated telephone reminder two weeks prior to the scheduled date of your procedure. During this phone call you will be able to confirm your appointment. If you do not get this call you must call us at (910) 235-3177 to confirm your appointment. 2. You must confirm your appointment no later than 7 days prior to your procedure date. If you do not, 3. If you confirm your appointment and then fail to arrive for your procedure and you have not given us at least 24 hours notice you will be charged $100.00 for not keeping your procedure appointment. 4. Please review these instructions carefully and write down any questions you may have. It is very important that you begin to follow these instructions at least 10 days prior to your appointment to ensure that you understand it and are able to follow the directions. We may be reached at (910) 235-3177 if you have additional questions. Please Note: Patients who are scheduled at the hospital will not receive a confirmation phone call from the nurse at the Pinehurst Medical Clinic. THE DAY BEFORE YOUR PROCEDURE:
You will receive a phone call from one of our nurses to remind you of your arrival time.


Microsoft word - nowak

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