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.