Patient’s name: _____________________________________
Date of procedure: __________________________________
1. You will need a 3 oz bottle of Fleet’s Phosphosoda
for your test. (Do not substitute any other
prep). You may purchase this product at most pharmacies.
2. You will need to stay on clear liquids
all day on __________________.
3. You will start your prep at 1:00 p.m. on _______________________. Take 1.5 oz. of the Fleet’s
Phosphosoda and mix with 8 ounces of clear liquid and drink. Drink 8 ounces of clear liquid
every hour (2:00, 3:00, 4:00, 5:00 and 6:00 p.m.). At 7:00 p.m. take the remainder of the prep.
Mix 1.5 ounces of the Fleet’s Phosphosoda with 8 ounces of clear liquid and drink. You will need
to drink 8 ounces of clear liquid every hour (8:00, 9:00 and 10:00 p.m.). You may drink clear
liquids up until midnight if you wish. Nothing after midnight.
4. If you have any problems with your prep, call the office at (256) 766-0150 and ask to speak with
your doctor’s nurse: _________________________________. She will be able to help you with
5. You may brush your teeth the following morning, but do not swallow any water and do not take
any medications or chew any gum until after your procedure.
6. Do not take any aspirin products or arthritis medications 7 days prior to your procedure. Stop
____________________________ on _________________________________. You may take
7. Someone needs to come with you the morning of your procedure to drive you home because the
medication you receive will impair your ability to drive. If you do not have a driver and
someone to stay with you, your procedure will have to be rescheduled.
8. The day before your procedure ____________________________ you need to call Pre-Admitting
at ECM between the hours of 10:30 a.m. and 7:00 p.m. to pre-register for your procedure. The
phone number is (256)768-8030. You will need the name of your health insurance company(s)
9. You will need to bring all medications taken on a daily basis with you the morning of your
procedure. If possible, diabetic patients should check their blood sugar before coming to the
10. Be at the endoscopy unit at 5:45 a.m. on the day of your procedure.
Clear Liquid Diet
Things that are included on a clear liquid diet:
Coffee – you may have 1 cup with a liquid breakfast, then no more coffee
Any type of clear soft drink (7 Up, Mountain Dew, Sprite, Ginger ale)
Jello, plain, any flavor except red or grape
Things that are not
included on a clear liquid diet:
Any soup with solid material such as noodles
Do not take any of the following products for 7 days prior to surgery
Cough and cold preparations:
Analgesics (pain tablets):
Coumadin, Trental, Heparin, Ticlid, Plavix, Mobic
Keystone/AmeriHealth Pharmacy & Therapeutic Committee Meeting Minutes December 8, 2009 Approval of Minutes 0 Against Old Business Committee requested in the October 2009 meeting to have a cardiologist/electrophysiologist to address efficacy, safety, and cost analysis of the Although several doctors were contacted, schedules did not permit them to attend the December
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