• Bring a current copy of your Advance Directive (i.e. Living Patient Name:__________________________________ Will or Medical Power of Attorney) to place in your medical Physician:_____________________________________ record, unless you have recently done so. Procedure Date:________________________________ Procedure Time:________________________________ Arrival Time:___________________________________ During this exam, you will receive intravenous (IV) medicine to relax you. For the first 24 hours after this medicine, you *Arizona Outpatient Surgery Center, 6245 N. 16th Street, *AZ West Endoscopy, 1850 N. 95th Ave Ste. 190 Therefore, the following is necessary for your safety: •Your exam WILL NOT be done unless you have a responsible *Banner Estrella Surgery Center, 9301 W. Thomas Road, adult accompany you home and be available to report any •Do not drive motorized vehicles or equipment for 24 hours. *Surgical Elite, 10815 W. McDowell Suite 101, *West Valley Hospital, 13677 W. McDowell, •Do not assume responsibility for young children or anyone •Avoid making important decisions or signing legal documents. •Do not travel by airplane for 7-10 days after your procedure. Bowel cleansing will be improved if you avoid eating lettuce, high fiber foods, seeds and vegetables for 2 days before • No Plavix, Trental, Aggrenox, Effient, Vitamin E, or NSAIDs (non- steroidal anti-inflammatory drugs) (1) week prior to procedure, for a full list of NSAIDs please see end of prep form. If this box is checked, you will require__________________ •No alcohol 2 days prior to procedure. clearance for your procedure. It is YOUR responsibility to • Stop all illegal drugs (including Marijuana) 7 days prior to procedure. Use of illegal, non-prescribed drugs (including Marijuana) could cause adverse side effects during your procedure. • If you are on any cardiac medications, please do not stop them • Inform your physician IMMEDIATELY if you take blood- until you get permission from your cardiologist. thinning medicine. If you are taken off your blood-thinning medicine before your exam, a test of the clotting time of your blood should be done the day before the exam. Your • Drink clear liquids only for the entire day. Do not drink any physician should check the results BEFORE you begin to drink • Eat NO solid food. No milk or milk products. • If you have a pacemaker or internal cardiac defibrillator, call • At 12PM (noon) take the Bisacodyl tablets. • At 6PM, drink bowel-cleansing prep (HalfLytely). It is best • Please stop taking iron medicine or vitamins with iron 10 • DRINK ONE EIGHT-OUNCE GLASS EVERY 10 to 15 MINUTES • If you have diabetes, please read the attached special directions. Check your blood sugar prior to exam check-in • Crystal Light lemonade powder may be added to unflavored time. Bring your glucometer to your appointment. • You may continue clear liquids during and after bowel • You may drink clear liquids up to 5-6 hours before your Serious problems with these exams are uncommon. Possible check in time. Nothing by mouth after _________AM problems include perforation (tear through the wall of the bowel) bleeding, infection, or drug reaction. You may discuss • Take your blood pressure and heart medications on the day all possible problems with your physician. of procedure with a sip of water. All other medications can wait until after the procedure. Do not take water Ensuring payment for all procedures (and associated costs) is YOUR RESPONSIBILITY. Our office will do its best to pre- Each patient may respond to the bowel cleansing drink certify the procedure with your insurance company. We differently. Contact your health care provider if you cannot know ahead of time, though, what your part of the cost of the procedure will be. The cost is different for every insurance company and every individual plan. If you have any concerns, you need to contact the customer service department of your insurance provider PRIOR to undergoing the procedure. Please remember to inquire about coverage for ancillary services such as the facility fees, anesthesia, and FAILURE TO FOLLOW THESE INSTRUCTIONS MAY RESULT IN A REPEAT EXAM OR CANCELLATION OF YOUR EXAM. You understand you are responsible for any deductibles, co- payments, co-insurance or amounts not covered by the Please remove and leave all jewelry at home. Insurance carrier for your procedure. You further understand any collection fees will also be your responsibility. In addition, you are aware that if you cannot attend your You will be asked to change into a gown. Your health history will be reviewed and your IV will be started. Then you will be scheduled procedure, you must call at least 48 hours in taken to an exam room. Your vital signs will be watched closely during the exam by a registered nurse. You will receive medication through your vein. This is called intravenous (IV) sedation. The purpose of this medicine is to It is normal to feel bloated, have gas cramps and pass large help you relax and make you more comfortable. It may make amounts of air. This will last until the air is expelled from your you sleepy but you will still be able to communicate with your You may resume taking your medications unless otherwise During the exam, the physician will insert a colonoscope, a thin flexible tube, through your rectum and into your colon. You may have a feeling of abdominal pressure or cramping if air and water are inserted through the tube. Resume your regular diet if no other tests are ordered. The scope has a small camera that sends pictures to a screen. The endoscope allows the physician to look closely at the inside of the colon for bleeding, inflammation and tumors. If you experience any of the following symptoms, call or go to There also is an open channel in the scope through which the • Pass blood clots or blood colors the toilet water red (some blood with the first bowel movement is normal). • Constant abdominal pain, with or without blood, up to 14 This exam usually takes between 20 to 40 minutes. When • Temperature of 100.4 degrees F. (38 degrees C.) or greater. your exam is finished, you will be taken to the recovery area If you have any questions about preparing for your where you will stay for about 30 to 45 minutes. colonoscopy or the exam itself, do not hesitate to speak with Your physician will give you the results of your exam by follow-up appointment, phone call or letter. NSAID’s: Non-Steroidal Anti-Inflammatory Drugs Aspirin (Anacin, Ascriptin, Bayer, Bufferin, Ecotrin, Excedrin) Choline and magnesium salicylates (CMT, Tricosal, Trilisate) Choline salicylate (Arthropan) Celecoxib (Celebrex) Diclofenac potassium (Cataflam) Diclofenac sodium (Voltaren, Voltaren XR) Diclofenac sodium with misoprostol (Arthrotec) Diflunisal (Dolobid) Etodolac (Lodine, Lodine XL) Fenoprofen calcium (Nalfon) Flurbiprofen (Ansaid) Ibuprofen (Advil, Motrin, Motrin IB, Nuprin) Indomethacin (Indocin, Indocin SR) Ketoprofen (Actron, Orudis, Orudis KT, Oruvail) Magnesium salicylate (Arthritab, Bayer Select, Doan’s Pills, Meclofenamate sodium (Meclomen) Mefenamic acid (Ponstel) Meloxicam (Mobic) Nabumetone (Relafen) Naproxen (Naprosyn, Naprelan) Naproxen sodium (Aleve, Anaprox) Oxaprozin (Daypro) Piroxicam (Feldene) Rofecoxib (Vioxx) Salsalate (Amigesic, Anaflex 750, Disalcid, Marthritic, Mono Sodium Salicylate (various generics) Sulindac (Clinoril) Tolmetin sodium (Tolectin) Valdecoxib (Bextra)


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