Fleets Phosphosoda Colon Preparation
Date your procedure is scheduled _____________________________________________________________ .
Please check in at (time) ____________ am/pm. Your procedure is scheduled for (time) ____________ am/pm at: _____ Tallahassee Endoscopy Center (DDC Building, 2nd floor) _____Tallahassee Memorial Hospital (Central Registration) _____ Capital Regional Medical Center (Admitting Office) A Few Days Before Your Examination:
You will need to purchase a 3 or 4 ounce bottle of Fleets Phosphosoda (a saline laxative) and Dulcolax tablets OR Milk of
Magnesia. This may be found in the laxative section of your pharmacy.
Two days prior to your exam ___________________ take either 2 Tablespoons of Milk of Magnesia OR 2 Dulcolax tablets at
The Day Before Your Examination Date ____________________:
You must maintain a clear liquid diet. Clear liquid diet includes: water, tea, Gatorade, black coffee, clear soda pop, clear
juice (apple, grape), jello (lemon or lime without added fruit), bouillon, or popsicles. NO SOLID FOOD ALLOWED.
At 8 am drink 3 Tablespoons of Fleet’s Phosphosoda laxative in a glass of water. Drink 4 eight-ounce glasses of water after the
Fleet’s Phosphosoda. Continue to drink liquids throughout the day.
At 6 pm drink the other dose of the 3 Tablespoons of Fleet’s Phosphosoda in a glass of water. Drink 4 eight-ounce glasses of
water after the second dose of Fleet’s Phosphosoda.
Continue with clear liquids throughout the evening at a minimum of 6 eight-ounce glasses of plain water or clear juice. Do not
eat or drink after midnight the night before the exam.
If your procedure is after 12:00 noon you may have clear liquids until
8:00 a.m. the day of your procedure.
If you feel your colon is not adequately prepared please let the OUTPATIENT nurses know when you arrive at the hospital /outpatient facility.
If you are taking blood pressure, heart, asthma, anti-depressents, thyroid, cholesterol or seizure medication and generally take this
medication in the morning, we DO want you to go ahead and take these medications the morning of your procedure with a sip of
Your procedure will be performed by:❐ Larry D. Taylor, M.D.
A well prepared colon is essential since stool in the colon may obscure lesions or block the channel of the scope. Failure to followthe instructions may result in an inadequate colon preparation, making it necessary to cancel your procedure.
Additional Instructions:
If you take insulin please check with the physician managing your diabetes for instructions regarding management of your diabetes
during this time period. Please bring your insulin, oral diabetes medications and your blood testing equipment with you on
the day of the procedure.

If you take aspirin / NSAID / Coumadin, please consult with your MD regarding holding this medication.
If you are taking coumadin make arrangements to have your blood drawn (for a PT) the day prior to your procedure.
If you have any questions, please call 877-2105.
You will be given instructions regarding your normal daily routine following the procedure at the time you are discharged from the
1. If applicable, D O follow your colon preparation
instructions. If you have questions regarding your colon
1. D O N ’ T eat or drink after midnight prior to your
preparation, please call, (850) 877-2105 for instructions.
2. If you are taking Coumadin, aspirin, Advil, Motrin,
Ibuprofen, or iron, DO hold these medications ____ days prior
2. D O N ’ T wear nail polish on at least one fingernail
to your procedure. Please resume your medications per your physician’s instructions. Tylenol is o.k. to take.
3. DON”T bring unnecessary valuables.
3. If you are taking Coumadin DO make arrangements to have
your blood drawn (for a PT) the day prior to your procedure.
4. DON’T drive or operate machinery the day of your
4. DO bring your medications the day of your procedure. DO
take your heart, blood pressure, seizure and asthma medications,if applicable, with a sip of water.
5. DON’T take herbal supplements or herbal medications
5. DO follow your insulin instructions per your primary care
physician. Please discuss with him or her your preparation for
the procedure, diet and time your procedure is scheduled. If
applicable, DO check your blood sugar prior to leaving your
house the morning of the procedure. Please bring your
glucometer, testing strips and insulin to the endoscopy center themorning of your procedure.
1. To provide care for all patients in a timely manner
6. DO wear casual clothes the day of procedure.
and maximize your physician’s time, please cancel your procedure as soon as possible and no later than 7. DO bring a copy of your insurance information and/or
4 days prior to your appointment. Call 877-2105 to payment. If you have questions regarding payment, please contact our billing specialist at (850) 942-4706.
8. DO make arrangements for someone to drive you home. It
2. To obtain biopsy results, you may call 1-866-436-6197.
is necessary to have a responsible adult available on discharge to You will be asked for your unique ID, (your social receive post-procedure instructions and to drive you home. If a security number) and your PIN number, (your date of birth responsible adult is not available to drive you home, sedation entered as mm/dd/yy, for example 12/05/45). You may also obtain results online at www.mytestresults.com. Youwill need to enter 8664366197 in the customer number There is adequate waiting space for you and one responsible field and your unique ID and PIN number as indicated adult. To prepare for your procedure, please arrive and check in 3. Your procedure is scheduled at:
DATE: _________________________________________ 2nd Floor of Digestive Disease Clinic ARRIVAL TIME _________________________ AM/PM Tallahassee Memorial HospitalCentral Registration PROCEDURE TIME ______________________ AM/PM Capital Regional Medical CenterOutpatient Registration Some medications we use can have amnesiac affect, for that reason, your responsible adult should be available uponcompletion of the exam for consultation with you and your 9. DO resume your normal daily routine the following day
unless specific instructions are given to you at the time of 10. If applicable: D O bring your implanted cardiac
defibulator/pacer identification card to the hospital on the day of

Source: http://www.ddctally.com/forms/fleets.pdf

Microsoft word - #1 connors dever jae 2005

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