West chester g

WEST CHESTER G.I. ASSOCIATES
Procedure Date: _______/______/______
Bowel Preparation with Gatorade, Dulcolax & Miralax
□ DO NOT EAT OR DRINK ANYTHING 4 HOURS BEFORE YOUR SCHEDULED ARRIVAL TIME.
□ You must be accompanied by a friend or relative to drive and/or assist you home. We WILL NOT discharge you to a
cab, bus or other transportation service without a responsible party with you. You may not drive for 12 hours following your
procedure.
Materials You Will Need to Prepare For Your Procedure
□ Purchase at the Store:
o Miralax, 8 oz. bottle (over the counter)
o Dulcolax Laxative or Bisacodyl (generic) Laxative over the counter
o Gatorade, 64 oz. bottle No RED OR PURPLE
□ Clear Liquid Diet Instructions (see attached Clear Liquid Diet Sheet)
Special Instructions Regarding Medications
□ Do Not take Iron supplements for one week prior to the procedure date. Multivitamins are OK.
□ Stop taking Coumadin/Plavix _____________ days prior to your scheduled procedure date.
□ Diabetic patients: ______________________________________________________________
□ Do Not take Lasix, HCTZ or Dyazide (water pill) the day of the procedure
□ Heart/Blood Pressure/ Thyroid/Seizure/Nerve Medications can be taken on the day of the procedure with a sip of water.
□ Stop Effexor one day before the procedure
□ Asthmatic patients should bring their INHALERS with them on the day of the procedure
□ Other _________________________________________________________________
The Day Before Your Exam
□ DO NOT EAT ANY SOLID FOODS. YOU MAY ONLY HAVE CLEAR LIQUIDS UNTIL 4 HOURS BEFORE
YOUR SCHEDULED ARRIVAL TIME.
□ Take all of your normal prescription medications, unless advised otherwise.
□ You may go to work, but be home by 6 pm to begin your bowel prep.
□ Prepare the Gatorade® and Miralax solution in the morning. Mix the entire 238g bottle of Miralax with the 64 oz bottle of
Gatorade® in a pitcher. Shake the solution until the Miralax is dissolved, then place in refrigerator.
PM Procedure
□ At 6 pm – Take four (4) Ducolax Laxative tablets with water.
□ At 6am (or earlier) on the morning of your procedure – Begin drinking the Gatorade and Miralax solution. Drink 8
ounces every 10-15 minutes - until the entire solution is consumed.
□ You must finish drinking this solution by 8 am.
□ WITH AN AFTERNOON PROCEDURE, you may have CLEAR LIQUIDS up to 4 hours prior to your Scheduled
arrival time.
 Question about symptoms or medications call 484-356-1050 between 7:30 am- 3:30 pm (Nurse Line)
 General or reschedule questions call 610-431-3122  If you reschedule, ask to see if you need new prep instructions. ______________________________________________________________________________________________________ Patient: Print Name Signature Date Gatora

Source: http://www.westchestergi.com/docs/Gatorade,_Dulcolax,_Miralax_PM_Prep_Instructions.pdf