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Microsoft word - bowel prep english web version may 1, 2013.doc
100 Renfrew Drive, Suite 130 (South Entrance)
DATE OF PROCEDURE
How to Prepare
Proper bowel preparation is essential to a safe and successful colonoscopy. You
will need to purchase an oral bowel cleanser and stool softeners (listed below)
two days before your procedure. These items can be found at your local
pharmacy. Failure to properly prepare will result in cancellation of your
appointment. Please call us if you have any questions regarding the following
Food containing seeds, nuts or corn should be stopped 48 hours before the
procedure. No solid food for the entire day before your procedure. Clear
Clear fluids include; water, pop, clear juices such as apple juice,
white grape juice, white cranberry juice (no orange juice), Gatorade and Jell-o
(no red or purple), consommé or clear broth soups, black coffee or tea (No
congee!). Drink at least 2 liters (about 12 large glasses) of water throughout the
day to help flush out your bowel.
Purchase one box (contains two sachets) of Pico-Salax.
You will also need to
purchase 2 tablets of Dulcolax
Take 2 tablets of Dulcolax
two days before your procedure. Take the tablets
after supper (this is your last solid meal). These tablets are stool softeners and
will not prevent you from going to work the next day.
is to be taken one day before your procedure. The first sachet is
to be taken at 5:00pm and the second sachet at 9:00pm that evening.
To prepare the Pico-Salax, add one sachet to 150mL (5oz) of cold water and stir for 2-3 minutes. The mixture may heat up while stirring. If so, let it cool and drink the entire contents. This is to be done once at 5:00pm and again at 9:00 pm. *Please note that the instructions on the box of Pico-Salax are different from our instructions. Please follow the instructions we give you!
Drink plenty of fluids until 4 hours before
your procedure. Example: If your
appointment is at 1:00pm, you must STOP drinking fluids at 9:00am.
If you are on any of the following medications, you will need to stop taking them for a
period of time. Please refer to the list below: Medication
If you are taking Coumadin (Warfarin),
please inform the receptionist upon booking
your appointment. Our Surgeons will review your medical history and we will provide you
with further instructions if needed.
Take all other medications (not listed above), as regularly prescribed, with a small sip of
water. Attention Diabetics
Take only HALF of your regular diabetic medication the day before the procedure. This includes oral medications and
On the day of the procedure do not take your diabetic medication until after your procedure is completed and you have had something to eat. You may then return to your regular dose of diabetic medication.
• Please arrive 15-30 minutes before your scheduled procedure with your
valid Ontario health card. Our staff needs to admit and prepare you for the procedure.
• Due to the nature of the medication you will be receiving, you
will be unable to drive for 24 hours. You MUST have someone
accompany you in order to drive you home. You are legally
impaired! Your driver must be available to pick you up at the
time your procedure is complete. Your visit at the clinic is
usually no longer than 90 minutes. Any form of public
transportation is not permitted.
• For non-English speaking patients, please bring an interpreter with you
(we do have Cantonese and Mandarin speaking staff available).
• There is NO additional charge
for your procedure or parking here at
Markham Endoscopy. However, there is a $150.00 fine for cancellations less than 48 hours prior to appointment time.
Woodbine Endoscopy 100 Renfrew Drive, Suite 130 (South Entrance) Markham, ON L3R 9R6 www.woodbineendoscopy.com tel: 905-948-9119 fax: 905-948-8358 Revised May 1, 2013
So that we may provide you with the best care, please fill out these forms completely. Mr. Mrs. Ms. Dr. Today’s Date Last name First name Middle initial Date of Birth / / Age Prefer to be called Address City State Zip Occupation Employer If married, please list Spouse’s name: If the patient is a minor please fill out the following: Parents or Guardians name: Address City State Zip Pe
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