Date Printed: Tue, May 04, 2010 Page 1 of 1

Time Printed: 3:20 PM Dale Prokupek, M.D.

Diplomate American Board of Internal Medicine and Diseases of the Gastrointestinal Tract
Assistant Clinical Professor of Medicine UCLA School of Medicine
8641 Wilshire Blvd Suite 100 Beverly Hills CA 90211 Phone 310.360-6807 FAX 310.360.6683

Colonoscopy Preparation Instructions for Patients: Golytely

Patient Name: Procedure Date: Procedure Time: Arrival Time: Pickup Time:

..
You have been prescribed "Golytely". Golytely is available at most retail pharmacy outlets. If your pharmacy does not have
Golytely in stock, it can be ordered and delivered within 24 hours. Information for your pharmacist: A240005

Preparation Instructions (Please read entirely; contact us with any questions).

Note: If you suffer from any heart condition, sleep apnea, or have an atrial defibrillator, notify us immediately. Do not
use MoviPrep if you are allergic to polyethylene glycol or any other electrolyte solutions (such as Pedialyte or Gatorade).

Three Days Prior to the Scheduled Procedure:

Discontinue any blood-thinning medications such as Aspirin (i.e. Ecotrin, Excedrin, Anacin, Coumadin), 3 days
prior to your scheduled procedure. If you are unsure if your medication is a blood thinner, ask us.

The Day before the Scheduled Procedure:

You may eat a regular diet (preferably light) up until 4:00 PM the day before the procedure. After 4:00 PM,
ONLY consume liquids from the following list. DO NOT consume anything Red or Purple in color!


Clear Broth flavored with Chicken, Beef, or Vegtable.
Plain Jello (Orange, Lemon-Lime Only, no toppings)
No solids

Popsicles (Orange, Lemon-Lime Only)


Lemon-Lime Sodas, Ginger Ale, Coffee, Tea, Water

Sports Drinks (No Red or Purple), Gatorade, etc.
Do Not Consume ANY food OR liquid after midnight and until the procedure is completed.

3:00 PM: Fill the Golytely jug to the 4 liter mark, add flavor pack(s), shake vigorously until dissolved, then chill.

4:00 PM: Begin consuming Golytely mixture at a rate of 240 mL (8 oz.) every 10 minutes, until 4 liters are
consumed or the rectal effluent is clear. Rapid drinking of each portion is preferred to drinking small
amounts continuously. Your full compliance is necessary to ensure a successful procedure!

The Day of the Scheduled Procedure:

Do not consume any food or liquids. Bring medications with you to the procedure and you may take them after the
procedure. You will be sedated during the procedure, therefore you cannot drive for the rest of the day. For legal
liability purposes, you must pre-arrange a ride home with a person who knows you personally; the procedure may
be canceled if this is not done. You will not be released from the procedure center to a Bus or Taxi. No water,
gum, hard candy, etc., the morning before your procedure.

PROCEDURE LOCATION
You must arrive at (Time to be Determined) at Tower Outpatient Surgery Center 8635 West 3rd
Street Suite 1085 West (Cedars Sinai Medical Towers, West Tower) Los Angeles, CA 90048
(310) 659-9408.

Please Note:
You may discover the instructions which come with the prescription preparation differ from the instructions we
have provided you with here. The instructions we have provided you on this form are specific to the procedure
you are receiving. Please follow these instructions, on this form.

Blue Cross:
Blue Cross / Anthem, by policy, does not cover anesthesia for endoscopy procedures (upper or lower). Based
on this information, you must advise us of your preferred sedation method: Light - $175.00, Full $350.00, Full
for both Upper and Lower $450.00
Note for BlueCross patients only: Light Sedation: $175.00 Full Sedation: $350.00 ($425 if Upper and Colonoscopy Combined)