Atul T. Shah, M.D., P.A.
Samir K. Nath, M.D., P.A.
Phone # (281)422-7970 Fax # (281)422-7960
COLONOSCOPY WITH POSSIBLE BIOPSY AND POLYPECTOMY
NAME:
SEX:
DOB:
PATIENT:
DATE:
DIAGNOSIS:
Abdominal pain
colon polyp
Family history of colon cancer
BM habit
Procedure Risks:
Rectal bleeding
Rule out
Rule out colitis
Change in
Perforation, Bleeding, Infection, and Medication Reaction
MOVI PREPARATION INSTRUCTIONS FOR THE PATIENT - EVENING BEFORE
A. Registration at:______________________________________________
Your Colonoscopy is scheduled at _________________ on _______,
____/____/200__at___AM
Pre-register at the hospital at least 72 hours prior to the procedure - [] Pregnancy
Test
* (Failure to register prior to your procedure, may result in cancellation of your
procedure.)
B. Preparation for the Colonoscopy
One week before the procedure:
 Do not take any form of Aspirin/ STOP VITAMINS
Three days before the procedure:
 Do not take NSAIDs (i.e., Advil, Ibuprofen) Tylenol is okay.
One day before the procedure ___________, _________/___________/200__. THAT
MORNING YOU WILL NEED TO (for your first dose) OPEN 1 OF THE CLEAR
PACKETS AND POUR THE A pouch and the B pouch of the MoviPrep in the
container provided. Fill with water to the fill line and refrigerate. Do this early in
the morning so the prep will be cold when you begin drinking it. All day long you
need to follow these instructions:
 No Solid Foods upon arising.
 Take clear liquid diet (Broth, Water, Juices, Jell-o, Coffee, Tea or Soda) Start
early in the morning.
 No milk or milk products. No liquids in red or purple color.
 Begin drinking the MoviPrep at 6:00 pm. Drink 8 oz. every 10-15 min. until it is
all gone. Once you have competed drinking the MoviPrep solution, drink (2) 8oz
glasses of clear liquid. This will keep you hydrated.
 As soon as you have completed drinking the first dose, mix the second dose. For
your second dose, open the remaining clear packet and mix the A pouch and the
B pouch of MoviPrep in the container provided with water and refrigerate.
 Begin drinking the second dose of MoviPrep at 10:00pm. Drink 8oz. every 1015 minutes until it is all gone. Once you have completed drinking the MoviPrep
solution, drink (2) 8oz. glasses of clear liquid. This will keep you hydrated.
 At midnight you can no longer have anything to eat or drink other than the
prep until after the procedure.
C. Day of the Procedure: On
*Bring your medications with you to the hospital. (IF YOU ARE A DIABETIC, DO
NOT TAKE THE DIABETES MEDICATION ON THE DAY OF PREPERATION)
*You must be at the endoscopy unit at least 1.5 hours prior to procedure time.
 Please be sure to bring your procedure order with you.(or you will be
rescheduled)
 You will need to bring someone with you to drive you back home.
Insurance Company: ___________________________
Schedule Completed by:
______________________
MAC
NO
YES
PEDISCOPE
NO
YES
_____________________________________________
Atul. T. Shah, M.D./ Samir K. Nath, M.D.