Microsoft word - web revised patient info profile updated 10-31-07-4.doc

SuPrep Bowel Prep Kit
When: date: _______________________________ time:
__________________________________ report: __________________________________________________________ Where:
_____ Raleigh Endoscopy Center Cary (919) 792-3061 _____ WakeMed Cary (919) 350-2300 _____ Rex Hospital Raleigh (919) 784-3100
CheCK In: BUSINESS OFFICE REGISTRATION/RECEPTION AREA.
PUrChASe: SuPrep Bowel Prep Kit (Rx), Magnesium Citrate 8oz (OTC).
Three/fIve dAyS PrIor To ProCedUre:
n Blood thinning medications such as Coumadin, Ticlid, Plavix, Aggrenox and Lovenox may need to be discontinued five days prior to the procedure . Please contact your prescribing physician for instructions well in advance. We will also seek clearance from said Physicians. Please note, as a rule we will require you to withhold all arthritis medications, aspirin, vitamin supplements, and herbal products. In addition, Pletal and Trental may also need to be withheld. You may take your blood pressure medication with a sip of water four hrs before the procedure 2 dAyS PrIor To ProCedUre: _____________________________________________________________________________________________________________________________
n AT 6:00PM TAKE 8OZ OF MAGNESIUM CITRATE WITH 8OZ OF FLUIDS.
n HYDRATE WELL PRIOR, DURING AND POST COLONOSCOPY.
one dAy PrIor To ProCedUre: __________________________________________________________________________________________________________________________
n If you take Insulin or other diabetic medications, you will take ½ (half) your usual dose at ___________AM.
n If you take an evening (PM) dose, test your sugar levels before taking any medication. Hold your (AM) dose on the morning of the procedure. You may resume your usual dose once you have restarted your normal diet.
CLeAr LIQUId dIeT onLy ALL dAy PrIor To ProCedUre.
n AT 6:00PM Pour the content of one bottle of SuPrep Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16oz. line, drink the entire amount.
n DRINK (2) ADDITIONAL CONTAINERS FILLED TO THE 16OZ. LINE WITH WATER OVER THE NEXT HOUR.
The dAy of yoUr ProCedUre: ___________________________________________________________________________________________________________________________
n AT _____________________________________________ AM, (FIVE HOURS PRIOR TO PROCEDURE) pour the content of the 2nd bottle of SuPrep Prep Kit into mixing container provided. Fill container with water to the 16oz. line, drink the entire amount.
n Drink (2) additional containers filled to the 16oz. line with water over the next hour.
n DO NOT EAT OR DRINK ANYTHING EXCEPT: ANY BLOOD PRESSURE MEDICATION, CARDIAC MEDICATIONS WITH A SIP OF WATER. NO ASPIRIN OR MEDICATIONS THAT ARE REQUIRED TO BE TAKEN WITH FOOD. n ARRIVE FOR COLONOSCOPY AT THE REPORTING TIME.
n A RESPONSIBLE ADULT MUST ACCOMPANY YOU TO THE HOSPITAL/FACILITY, DRIVE YOU HOME UPON DISCHARGE n IF ANY CONDITION ARISES DURING OR AFTER THE PROCEDURE THAT NECESSITATES HOSPITALIZATION, THEN YOU n THERE WILL BE A $50.00 FEE TO RESCHEDULE OR CANCEL ANY PROCEDURE WITH LESS THAN 48HRS NOTICE.

Source: http://carolinagi.com/pdfs/patientprep_SuPrep.pdf