Please read and follow ALL instructions carefully from the given sheet and put [x] on your accomplishments below:

Several days before your procedure you must fill your prescriptions

[ ] Golytely 1 gallon

[ ] Four (4) Bisacodyl tablets (5 mg) 

Note: Medication works differently with each person. This medication will cause multiple bowel movements; this medication often works within thirty (30) minutes, but may take as long as three (3) hours; Please stay near toilet facilities.

The day before your procedure:

[ ] You may have “CLEAR LIQUIDS” ALL day. Nothing else!

What is considered a “clear liquid”?

Strained Fruit Juices (you can see through) (apple, white grape, lemonade), water, clear soup or bullion, coffee or tea (WITHOUT milk or non-dairy creamer), Gatorade, carbonated and non-carbonated soft drinks, Kool-Aid ( or other flavored drinks). Plain Jell-O (without added fruits or toppings), ice Popsicles.

REMEMBER..DO NOT EAT OR DRINK ANYTHING RED! The red dye in foods will cause changes in the color of your intestine, which may cause a problem with the test.

[ ] At 9:00 AM, take the 2 Bisacodyl Tablets with approved “clear liquids”.

[ ] At 4:00 PM, start mixing the Golytely power with one gallon of water or any approved clear liquids; Start drinking an 8 oz of glass every 10 to 15 minutes until 3 liters or 3/4 quarters of the liquid is finished within 2 hours.

[ ] At 9:00 PM, take the 2 Bisacodyl tablets with approved “clear liquids”.

The Day of Procedure:

[ ] At 2:00 AM on the day of procedure, drink the last (1/4) quarter of the Golytely before 4:00 AM.

[ ] My bowel preparation quality is clear and I am ready for the Colonoscopy!

[ ] After the preparation, DO NOT EAT OR DRINK until after the colonoscopy procedure is finished.

If your mouth is parched/ dry, the best way to help is to brush your teeth. This will help you feel more comfortable.

If you should have any questions at all, no question is a “dumb” question. please call Ambulatory Surgery (718) 883-2331 and we will help you.