DR.ATUL T. SHAH, M.D., P.A.
DR.SAMIR K. NATH, M.D., P.A.
Phone # (281)422-7970
Fax # (281) 422-7960
COLONOSCOPY WITH POSSIBLE BIOPSY AND POLYPECTOMY
NAME:
SEX:
AGE:
DOB:
PATIENT HOME #
DIAGNOSIS:
[] Family Hx of colon ca
[] Rule out colitis
[] Change in BM Habits
[] Personal hx colon polyp
[] h/o diverticulosis
[] Guaiac Positive Stool
Procedure Risks: Perforation, Bleeding, Infection, and Medication Reaction
SUPREP BOWEL PREP KIT INSTRUCTIONS FOR PATIENT
(PLEASE FOLLOW THESE INSTRUCTION CAREFULLY)
A. Registration at :________________________________
Your Colonoscopy is scheduled at __________on _____________,
________,____@______am/pm
Pre-register at the hospital at least 72 hours prior to the procedure/( ) Pregnancy Test
*(Failure to register prior to the procedure may result in cancellation of you
procedure.)
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.
B. One day before the procedure on _______________________________
 No solid foods upon awakening
 Take a liquid diet (Broth, Water, Juices, Jell-o, Coffee, Tea or Soda) Start early
in morning.
 No milk or milk products. No liquids in red or purple color.
STARTING SUPREP BOWEL PREP KIT to clean the bowel.
At 12:00 pm pour ONE (1) 6-ounce bottle of SUPREP liquid into the mixing container.
 Add cool drinking water to the 16-ounce line on the container and mix.
 Drink ALL the liquid in the container.
 You MUST drink two (2) more 16-ounce containers of water over the next 1 hour.
 Then at 10:00 Pm repeat step (1.)
 Nothing after midnight.
C. Day of Procedure:
Be at the _________________Endoscopy Unit by ___am.
Please bring your procedure orders/instructions with you. (or you may be rescheduled)
Bring your medications with you. DO NOT TAKE THEM.
You will need to bring someone with you to drive you back home.
*SPECIAL INSTRUCTIONS:_______________________________________
Insurance Company:__________
Schedule Completed by:___________
MAC []NO [] YES
PEDISCOPE [] NO
[]YES
Atul T. Shah, M.D./Samir K. Nath, M.D