Prep forms

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Download Prep Form (PDF, 29KB)

"The Easy Prep" with PEG 3350

NOTE: You must have a driver present when you arrive for your procedure.
Your driver must remain in the waiting room during your procedure.
Public transportation or cabs are not allowed.

Your Medication

If you take Coumadin, Plavix, Aggrenox, Effient, Pradaxa, or any blood thinners, please notify our staff if you have not received instruction regarding this medication.. Blood pressure and heart medication must be taken the morning of the procedure.

Diabetic patients patients should take ½ the usual dose of insulin/diabetes medication while on this prep diet. No insulin or other diabetes medication should be taken the morning of the procedure. Please check your blood sugar the morning of the procedure and tell your nurse the reading.

Prep: PEG 3350 ELECTROLYTE SOLUTION. This must be purchased at your local pharmacy. (Rx provided)

IMPORTANT: In addition to the prep, please drink additional clear liquids before, during and after drinking the prep solution. STOP DRINKING LIQUIDS 3 HOURS BEFORE YOU ARE SCHEDULED TO ARRIVE AT IMA Endoscopy SurgiCenter or the procedure will be cancelled and rescheduled. Not even a sip!!

DIET: The day before the procedure eat a light breakfast and lunch (by noon). This could include eggs, white bread, pasta, and rice. Please do not eat fresh/raw fruits or vegetables. After lunch you must start your clear liquid diet. Please look on the back of this page for acceptable choices. Do not drink any dairy products or anything containing artificial red dye.

Mix the gallon of PEG solution with water and chill in the refrigerator for several hours.

• Drink ½ of the gallon of the solution starting at 6:00 p.m. the evening before the procedure. It may take 1 to 2 hours to finish the first half of the prep solution. Many patients find the solution is better tolerated if you drink ginger ale or 7-Up in between glasses of PEG solution.
• Drink the remaining ½ gallon of the PEG solution starting at _________________ a.m. /p.m. on _____________________________________________ (DAY/DATE) . Splitting the dose of the prep solution provides you the best colon exam possible.

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IMA Endoscopy SurgiCenter is an Accreditation Association for Ambulatory Health Care (AAAHC) accredited facility and is owned and operated by the physicians of Internal Medicine Associates.

IMA Endoscopy SurgiCenter physicians and staff encourage your participation in your care. If you or your family have any concerns related to your care, treatment, services or patient safety while under our care, please discuss this with your physician or contact the Clinical Director/Administrator at 219-736-4660 ext. 138. If the issue cannot be resolved at this level, please contact the AAAHC at 847-853-6060; or the Indiana State Department of Health, Director of Acute Care, 2 North Meridian, Indianapolis, IN 46204; or by phone at 866-220-5810; or the Medicare Beneficiary Ombudsman at 800-MEDICARE, or online at www.cms.hhs.gov/ombudsman/resources.asp