Colonoscopy Instructions

PATIENT NAME: ______________________________________ DOB: ______________

PHYSICIAN: ______________________________________

PROCEDURE DATE: _________________ ARRIVAL TIME: ______________________

LOCATION:
q MAIN LINE ENDOSCOPY EAST: 2 BALA PLAZA, SUITE IL 30, BALA CYNWYD
q MAIN LINE ENDOSCOPY SOUTH: RIDDLE HOSPITAL, HCC II, SUITE 2407, MEDIA
q MAIN LINE ENDOSCOPY WEST: 325 CENTRAL AVE., LOWER LEVEL, MALVERN
q LANKENAU GI LAB: 100 E. LANCASTER AVE, APC MAIN ENTRANCE, WYNNEWOOD
q RIDDLE HOSPITAL MPU: OUTPATIENT PAVILLION, 2ND FLOOR, MEDIA
q PAOLI HOSPITAL SPU – 255 W. LANCASTER AVE., ENDOSCOPY SUITE, PAOLI

OFFICE PHONE NUMBER: 610-644-6755 HOURS 7:30 AM – 4:30 PM

YOUR MEDICATION INSTRUCTIONS: _____ initial here

q Stop taking medications with Iron 5 days prior to the procedure.

q Stop taking fish oil supplements 3 days prior to the procedure.
q Continue all prescribed medications unless otherwise instructed, including Aspirin and Plavix. If
you are prescribed a rescue inhaler, please bring it with you the day of the procedure.
q Stop any blood thinning medications only if you were instructed to do so.
q Take your medications 4 hours before your scheduled procedure with a sip of water. If you are
not able to take them 4 hours before your procedure, please wait until after your procedure.
q Do not drink any fluid within 4 hours of your procedure or it may be rescheduled .
q Diabetics: If you have diabetes, check with your primary care or prescribing physician to see if
changes are needed. Do not take your usual oral diabetic medications the morning of your
procedure. Check your blood sugar before arrival. Call the office at 610-644-6755, if your blood
sugar is 70 or below. Notify the staff immediately upon arrival as well.
q Do not smoke the day of the procedure.
q SPECIAL MEDICATION INSTRUCTIONS:

_______________________________________________________________________________
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 What is a Colonoscopy?

A colonoscopy is a test that allows the physician to examine the lining of the large intestine
with a thin flexible instrument. Polyps, or small growths, can be removed to prevent colon
cancer. Biopsies can be taken to diagnose other diseases.

 An intravenous (IV) catheter will be inserted into a vein in your arm to provide hydration
and medication to keep you asleep during your procedure.

 You will receive nasal oxygen. We will monitor your heart rate, blood pressure and blood
oxygen level throughout the procedure.

 Air or carbon dioxide and water will be placed into your colon during the exam. It is
normal to expel these after the procedure.

 You will rest in the recovery room after the procedure until you can tolerate liquids, walk
unassisted, and have stable vital signs.

THE ENTIRE PROCESS TAKES ABOUT 2 HOURS.

If the start of your procedure is delayed, we will do our best to keep you informed. Rest
assured that during your colonoscopy you will receive the highest quality care.

IMPORTANT
48 HOURS NOTICE IS REQUIRED FOR CANCELLATION.
IF YOU CANCEL LESS THAN 48 HOURS BEFORE YOUR PROCEDURE, YOU WILL BE CONSIDERED A “NO
SHOW” AND CHARGED A $50 FEE. THIS FEE IS NOT COVERED BY INSURANCE.

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 PREPARATION: 1 Week Before Your Procedure
 You will receive anesthesia during the procedure, so a responsible adult MUST accompany you
to your colonoscopy. This person MUST bring you to the office AND then bring you home. The
side effects of anesthesia are sometimes dizziness, forgetfulness and sleepiness therefore:
 A responsible adult must accompany you and stay with you if you take public
transportation.
 Bus, taxi, shuttle, Lyft or Uber drivers CANNOT be your responsible driver.
 If you are scheduled for an AFTERNOON procedure, a responsible adult MUST accompany
and STAY with you during the length of the procedure. If not, your procedure will be
rescheduled.

 Medication: See page 1.

 Purchase Prep:

Yo A “Colonoscopy Prep Kit” can be purchased for $20 at one of our convenient office
locations listed below. This kit includes the necessary prep, simethicone and 4
laxative tablets. Please read the directions carefully when mixing your prep.

 2050 West Chester Pike, 3RD Floor, Havertown

 100 Lancaster Avenue, Suite 252, Lankenau MBE, Wynnewood
 325 Central Avenue, Suite 200, Malvern
 1088 W. Baltimore Pike, HCC II, Suite 2407, Media

Or you may purchase your own:

Miralax Laxative Powder (238g or 8.3 oz)

This will be mixed with 64 oz. clear liquid of your choice:

Clear juice (apple, white grape, lemonade), Gatorade or similar sports drinks,
Kool Aid, or Crystal Light. No red or purple juice. No juice with pulp. No dairy
drinks. No alcohol.

Dulcolax: four 5 mg tablets

Simethicone (Gas-X): two 125 mg tablets

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 PREPARATION: 2 – 3 Days Before Your Procedure
DO:
Drink plenty of fluids – at least eight 8 oz glasses per day.
This will help avoid dehydration, make the prep work more
effectively and make you feel better overall.

DO NOT:
Do not eat any of the following foods, as they can remain in your colon after the
completion of your prep:
 Seeds  Whole grains  Corn
 Nuts  Beans  Peels of fruits or
 Oatmeal  Peas vegetables

A successful colonoscopy is collaboration between you and your physician. Following these
instructions is necessary so the physician can properly perform the procedure.
Failure to follow these directions may result in a poor prep and the need for your procedure to be
repeated or rescheduled.

 Medications:
Review any personalized instructions on page 1.
 Responsible Adult:
Review requirement for the person accompanying you to your procedure on page two.
Remember, if you are scheduled for an AFTERNOON procedure, a responsible adult MUST
accompany and STAY with you during the length of the procedure until discharge.

 Other Items:
 Wear comfortable clothes. You may feel bloated after the procedure.
 Leave valuables at home or with the adult accompanying you.
 Remove all jewelry, including body piercings.

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 PREPARATION: The Day Before Your Procedure

No Solid Food Starting at 12 noon today

Eat a fiber-free breakfast including any or all the following:

Before 12 noon  2 fried or boiled eggs

the Day Before  1/2 cup milk
your Colonoscopy  1/2 cup yogurt (not red or purple or with pieces of other foods)
 Up to 2 slices of cheese
 2-3 slices of White Bread
 1 Tablespoon butter or olive oil

Follow a diet of CLEAR LIQUIDS ONLY:

 Water
 Coffee or tea, without milk or cream
After 12 noon  Clear juice – apple, white grape, lemonade (no pulp)
the Day Before  Broth, bouillon
your Colonoscopy  Gatorade or similar sports drinks
 Kool Aid, Crystal Light
NO SOLID FOOD  Carbonated soft drinks – Coke, Sprite (regular or diet)
 Jell-O™ (no added fruit or toppings; not red or purple)
 Popsicles (not red or purple)
 NO RED OR PURPLE JUICE
 NO JUICE WITH PULP
 NO DAIRY DRINKS
 NO ALCOHOL

Take four 5 mg Dulcolax Tablets with 8 oz. water.

2:00 pm
the Day Before Prepare the prep: If you purchased your prep in the office, please follow
your Colonoscopy the mixing instructions carefully. If purchased on your own, mix the entire
bottle of Miralax (Polyethylene glycol) 238 g in 64 oz of clear liquid.
NO SOLID FOOD
Find a nearby bathroom!
First Dose of Liquid Prep (32 oz):
6:00 pm
the Day Before  Drink 8 oz’s of liquid prep every half hour for 2 hours while also
your Colonoscopy drinking four to eight 8 oz. glasses of clear liquid.
 Try your best to do this to prevent dehydration.
NO SOLID FOOD

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 PREPARATION: The Day of Your Procedure
No Solid Food Today Prior to your Procedure
6 HOURS Second Dose of Liquid Prep (32 oz):
BEFORE YOUR APPOINTMENT
 Drink 8 oz’s of liquid prep every half hour for 2 hours while also
drinking four to eight 8 oz. glasses of clear liquid.
NO SOLID FOOD
 Take 2 Simethicone (Gas-X) tablets after completing the Miralax
drink.
 Try your best to do this to prevent dehydration.
 The goal is to have slightly yellow and liquid stool
 This is the time when morning medications should be taken or
wait until after your procedure.
4 HOURS All prep and clear liquids MUST be completed 4 hours prior to your
BEFORE YOUR APPOINTMENT appointment.

No additional liquids or your procedure may be rescheduled.

NO FOOD OR DRINK
No hard candy, chewing gum or medications.

Nothing by mouth.

AFTER YOUR COLONOSCOPY

For routine questions, call our office at 610-644-6755 between 7:30AM and 4:30PM.

IF YOU HAVE AN URGENT CONCERN, CALL 610-644-6755 TO REACH OUR ON-CALL PHYSICIAN AFTER
HOURS.
 Rest and relax for the remainder of the day.
 We recommend that a responsible adult stay with you for 24 hours following your procedure.
 Resume your normal diet slowly and as tolerated.
 A feeling of fullness or cramping from remaining air or carbon dioxide may occur. This is totally
normal. Mild activity such as walking will help to expel any excess gas. Lying on your left side or
directly on your stomach may also help.
 Do not drive or operate any machinery, sign any legal documents, or make critical decisions or
return to work until the next day.
 Do not drink alcohol or take any unprescribed medication.
 Mild abdominal discomfort or a small amount of rectal bleeding is not unusual after the
procedure. However, if you experience significant pain, rectal bleeding, fever and vomiting or
any other worrisome symptoms please notify your physician immediately.
 Follow up with your physician’s recommendations for continued colon health.

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