(GENERAL INSTRUCTIONS, OPTIONS A, B, C - BE SURE TO ONLY USE THE OPTION SPECIFIED BY YOUR PHYSICIAN) GENERAL INSTRUCTIONS: YOU ARE SCHEDULED TO HAVE A COLONOSCOPY ON _____________________ AT PHELPS MEMORIAL HOSPITAL'S AMBULATORY SURGERY UNIT. PLEASE REGISTER AT THE AMBULATORY SURGERY REGISTRATION DESK LOCATED ON THE THIRD FLOOR OF THE HOSPITAL AT __________________. YOU HAVE TO STOP TAKING ASPIRIN, IBUPROFEN (ADVIL/MOTRIN) 3 TO 4 DAYS BEFORE THE PROCEDURE -PLEASE DISCUSS THE TIMING OF THIS WITH THE DOCTOR, PARTICULARLY IF YOU HAVE A HEART CONDITION. IF YOU ARE TAKING ANY NON-STEROIDAL MEDICATIONS (NSAIDS) FOR ARTHRITIS OR OTHER INFLAMMATORY CONDITIONS, DIABETES MEDICATION, ANTICOAGULANTS SUCH AS COUMADIN, OR ANY IRON SUPPLEMENTS, PLEASE MAKE THE DOCTOR AWARE OF THIS. YOU WILL REQUIRE INSTRUCTIONS ON HOW TO TAKE THESE MEDICATIONS PRIOR TO YOUR PROCEDURE. IF YOU NEED TO TAKE ANTIBIOTICS PROPHYLACTICALLY BEFORE DENTAL WORK, PLEASE ALSO MAKE THE DOCTOR AWARE OF THIS. CERTAIN INSURANCE COMPANIES REQUIRE "PRIOR AUTHORIZATION" OR "SECOND SURGICAL OPINION" FOR THIS PROCEDURE. PLEASE MAKE THE DOCTOR OR OFFICE STAFF AWARE OF YOUR INSURANCE STATUS PRIOR TO HAVING YOUR PROCEDURE TO AVOID A POSSIBLE PAYMENT PENALTY. IF YOUR INSURANCE REQUIRES A PAPER TYPE REFERRAL, IT MUST BE PRESENTED TO THE OFFICE PRIOR TO HAVING THE PROCEDURE. SINCE I.V. SEDATION WILL BE GIVEN FOR THIS PROCEDURE, IT IS VERY IMPORTANT THAT YOU ARRANGE FOR SOMEONE TO DRIVE YOU HOME. YOU MAY NOT LEAVE UNESCORTED OR BE ALLOWED TO TAKE PUBLIC TRANSPORTATION (TAXI, BUS, ETC.) TO YOUR HOME. IF YOU ARE EMPLOYED YOU SHOULD NOT EXPECT TO RETURN TO WORK AFTER YOUR PROCEDURE. DUE TO THE ADMINISTRATION OF I.V. SEDATION, YOU WILL BE INSTRUCTED NOT TO DRIVE A MOTOR VEHICLE OR OPERATE HEAVY MACHINERY FOR AT LEAST 12 HOURS FOLLOWING THE PROCEDURE. ALLOW YOURSELF 2 TO 3 HOURS FROM TIME OF REGISTRATION TO TIME OF DISCHARGE. ON THE DAY OF YOUR SCHEDULED PROCEDURE, PLEASE BRING ALL INSURANCE INFORMATION (CARD(S)/ REFERRAL IF NECESSARY, ETC.) TO THE HOSPITAL. ALSO, PLEASE BE PREPARED TO PAY AN INSURANCE CO-PAY AMOUNT, IF YOUR PARTICULAR PLAN REQUIRES ONE FOR THE HOSPITAL. YOU WILL BE ASKED TO SIGN A CONSENT FOR DR. BARRY FIELD TO PERFORM THE COLONOSCOPY WITH POSSIBLE BIOPSY AND/OR POLYPECTOMY. OPTION A: COLONOSCOPY PREP USING FLEET PHOSPHO-SODA. ORAL SALINE LAXATIVE
DAY BEFORE EXAMINATION Drink only clear liquids for lunch and dinner. Solid foods, milk and milk products are not allowed. CLEAR LIQUIDS INCLUDE:
*PLEASE AVOID ALL LIQUIDS THAT ARE COLORED RED OR PURPLE At 5 P.M. ADD ALL CONTENTS OF ONE 1 - OZ. BOTTLE OF FLEET PHOSPHO-SODA TO ONE FULL 8 OZ. GLASS OF CHILLED *CLEAR LIQUID (*Diluting Fleet Phospho-soda with Ginger Ale, 7 UP, Sprite or Apple Juice dramatically improves the taste). DRINK RAPIDLY (drinking this mixture through a straw will also make it easier to tolerate), IMMEDIATELY FOLLOW THE 1st DOSE OF LAXATIVE WITH 8 OZ. OF CLEAR LIQUID OF YOUR CHOICE. FROM THIS POINT UP UNTIL YOUR 2nd DOSE OF LAXATIVE, YOU MUST HAVE AN ADDITIONAL 4 CUPS (8 oz. Each) OF CLEAR LIQUIDS. YOU MAY HAVE ADDITIONAL AMOUNTS OF CLEAR LIQUIDS IF DESIRED, HAVING MORE CLEAR LIQUIDS ACTUALLY HELPS PROMOTE BETTER ELIMINATION. At 8 P.M. TAKE YOUR SECOND DOSE OF FLEET PHOSPHO-SODA (1 œ OZ. BOTTLE) THE SAME WAY AS DESCRIBED ABOVE. *THIS PREP WILL CAUSE YOU TO HAVE MULTIPLE BOWEL MOVEMENTS. PLEASE REMAIN WITHIN EASY REACH OF TOILET FACILITIES ONCE YOU BEGIN THE LAXATIVE PART OF THIS PREP. DAY OF EXAMINATION DRINK CLEAR LIQUIDS AS DESIRED UP UNTIL 3 HOURS PRIOR TO ARRIVAL. TAKE ANY NECESSARY MEDICATIONS (ESPECIALLY ANY BLOOD PRESSURE MEDS). OPTION B:
Drink only clear liquids for lunch & dinner. Solid foods, milk and milk products are not allowed. CLEAR LIQUIDS INCLUDE:
*PLEASE AVOID ALL LIQUIDS THAT ARE COLORED RED OR PURPLE. _______P.M. ADD ALL CONTENTS OF ONE 1 - OZ. BOTTLE OF FLEET PHOSPHO- SODA TO ONE FULL 8 OZ. GLASS OF CHILLED * CLEAR LIQUID (*Diluting Fleet Phospho- soda with Ginger Ale, 7 UP, Sprite or Apple Juice dramatically improves the taste). DRINK RAPIDLY (drinking this mixture through a straw will also make it easier to tolerate). FROM THIS POINT UP UNTIL YOUR SECOND DOSE OF LAXATIVE, TOU MUST HAVE AN ADDITIONAL 4 CUPS (8 oz. Each) OF CLEAR LIQUIDS. YOU MAY HAVE ADDITIONAL AMOUNTS OF CLEAR LIQUIDS 1F DESIRED, HAVING MORE CLEAR LIQUIDS ACTUALLY PROMOTES BETTER ELIMINATION. *THIS PREP WILL CAUSE YOU TO HAVE MULTIPLE BOWEL MOVEMENTS. PLEASE REMAIN WITHIN EASY REACH OF TOILET FACILITIES ONCE YOU BEGIN THE LAXATIVE PART OF THIS PREP.
________ A.M. TAKE YOUR SECOND DOSE OF FLEET PHOSPHO-SODA (1 œ OZ. BOTTLE) THE SAME WAY AS YOU TOOK YOUR FIRST DOSE THE EVENING BEFORE. DRINK CLEAR LIQUIDS AS DESIRED UP UNTIL 3 HOURS PRIOR TO ARRIVAL. TAKE ANY NECESSARY MEDICATIONS (ESPECIALLY ANY BLOOD PRESSURE MEDS). OPTION C: INSTRUCTIONS FOR COLONOSCOPY PREP WITH GOLYTELY, COLYTE, OR NULYTELY. DAY BEFORE EXAMINATION Drink only clear liquids for lunch and dinner. Solid foods, milk and milk products are not allowed. CLEAR LIQUIDS INCLUDE:
You will need to take a liquid bowel prep called Golytley, Colyte, or Nulytely in addition to following a "clear liquid" diet before your procedure. You may purchase this liquid bowel prep at most pharmacies. When you have your prescription for Golytely, Colyte, or Nulytely filled out at your pharmacy, you will have to add water to the prep, which will be in a powdered form in a plastic (gallon) container. Follow mixing directions on the container or ask your pharmacist for help. The liquid prep should be prepared in the morning on prep day (day before examination). Most patients prefer to refrigerate the liquid prep once it's mixed, making it more palatable for drinking later on that evening. Start drinking Golytely, Colyte or Nulytely on __________________at 5:00 or 5:30 p.m. Drink one 8 oz. Glass every 10 to 15 minutes until you complete the whole gallon, if possible. This prep will cause you to have multiple bowel movements. Often starts to work within 30 minutes. Please remain within easy reach of toilet facilities. It is important that you try to evacuate all of your colon content. Continue to drink clear liquids as desired up until 3 hours prior to your arrival time. If you have to take prescribed medication on the morning of your exam, you may do so. Arrive for colonoscopy at scheduled time _______________ on _________________.
Westchester Gastroenterology Associates, P.C.
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