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
UMKC Dental School Commonly Prescribed Prescriptions Comment: Most dental practitioners will prescribe a relative small number of prescription medications. It is the responsibility of the dentist to be familiar with all medications they are using in their practice, including side effects, patient instructions, drug interactions, etc. It is strongly recommended you have immediate a