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:
DOB:
SEX:
AGE:
PATIENT HOME #
DIAGNOSIS:
Abdominal pain
Family history of colon cancer
Personal h/o colon polyp
Anemia
Rectal bleeding
Rule out colitis
H/o diverticulosis
Rule out colon polyp
Change in BM habits
Guaiac positive stool
Procedure Risks: Perforation, Bleeding, Infection, and Medication Reaction
TRILYTE PREPARATION INSTRUCTIONS FOR THE PATIENT
(Please follow these instructions carefully)
A. Registration at Facility:
Your Colonoscopy is scheduled at ________ on _______, ____/____/20__at___AM
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 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 on ___________, _________/___________/20__.
 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.
Starting Trilyte to clean the bowel.
 You need one gallon of distilled water and refrigerate. Get Trilyte prescription filled.
 Drink Trilyte starting at 10:00am until 1:00pm or, as directed. You may flavor per glass with Crystal
Light or Lemon Juice. Take four Dulcolax tablets at one time after Trilyte.
 While drinking Trilyte, if you experience nausea, wait for one hour and start drinking again.
 If, after one hour interval, you are still unable to drink the Trilyte call (281) 422-7970.
 Resume clear liquid diet. It is important to drink liquids, so as not to get dehydrated.
 NOTHING TO EAT OR DRINK AFTER MIDNIGHT,OR THE MORNING OF PROCEDURE
C. Day of the Procedure:
 Be at___________________ Endoscopy Unit at ______ am.
 Please be sure to bring your procedure orders with you. (or you will be rescheduled)
 Bring your medication 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.