SANTA BARBARA GASTROENTEROLOGY CONSULTANTS MEDICAL GROUP Name: __________________________ Facility: ☐ Santa Barbara Endoscopy Center
☐ Santa Barbara Cottage Hospital Procedu x e Date: _________________ Check In Time: __________________ ☐ Santa Ynez Cottage Hospital
COLONOSCOPY PREPARATION SHEET: GOLYTELY/ DULCOLAX
5 Days Prior 4 Days Prior 3 Days Prior 2 Days Prior One Day Prior Colonoscopy Day
☐ Arrange a
☐ Drink AT LEAST ☐ Drink AT LEAST 8 glasses of
☐ Beginning at 4 hours before your colonoscopy, drink Golytely–8 ounce glass every 15 minutes until four glasses have been ingested
☐ Follow a strict clear liquid diet pharmacy with CANCEL
☐ After the last dose of Golytely, do not eat or drink anything. You
☐ Take 1 Dulcolax 5 mg tablet at BUT AVOID: - Raw fruits
☐ After bowel movement occurs
☐ Confirm your - Raw vegetables (or no later than 5pm), drink 8 - Nuts or popcorn oz. glass of Golytely every 15 - Foods with small minutes until four glasses have completed seeds such as been ingested
☐ If no BM occurs by 8 pm, continue drinking one 8 oz. glass of Golytely every 15 minutes until you have had a BM or until 8 glasses have been ingested
☐ Verify that patient questionnaire - Insurance Card
Consider stopping all casual (not Dr. recommended) Aspirin or
NSAIDS-no ibuprofen, Advil, Aleve, naproxen, Excedrin---only Tylenol is okay
SANTA BARBARA GASTROENTEROLOGY CONSULTANTS MEDICAL GROUP Notes and Suggestions Directions for Facilities
“Clearfluids” means liquids that you can hold up to the light and see Santa Barbara Endoscopy through. Examples: Juices without pulp, sodas, coffee, tea, Jell-O, broth, Center is at 25 W. Micheltorena
Gatorade and similar sports drinks. NO RED OR PURPLE
Use the Golytely preparation solution as per the written directions on the
Diarrhea will occur during the preparation. Stay at home near the bathroom
Santa BarbaraCottage
Irritation at the anal canal may occur. Vaseline applied to the skin around the
Hospital admitting office is in the
anus may protect from burning later during the prep.
YOU MAY NOT DRIVE HOME AFTER THE PROCEDURE. You are advised not to drive the entire day. A responsible adult must accompany you
home, even if you are taking a taxi or bus. Your procedure will be canceled if
you have not made appropriate arrangements
Post Procedure instructions will be given to you at the facility when you are
Santa Ynez Cottage Hospital
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