Colonoscopy and Other Procedure Prep Forms

In preparing for your colonoscopy or other procedure use the appropriate prep form, as directed by your provider. The forms are available in English and Spanish. Click the link below to view your form. If you have questions about your prep instructions or can find your prep from below, contact your provider.

All Illinois Patient Prep Forms- English

Capsule Instructions CLENPIQ AM Prep CLENPIQ PM Prep EGD Prep ELG Anorectal Manometry ELG Esophageal Manometry Esophageal EUS Flex Sigmoidoscopy Prep Flex Sigmoidoscopy with Magnesium Prep Magnesium Citrate Dulcolax Prep MiraLAX Gatorade Prep NuLytely or GoLytely or TriLytely AM NuLytely or GoLytely or TriLytely PM PLENVU AM Prep PLENVU PM Prep Rectal EUS Prep SUPREP AM Prep SUPREP PM Prep SUTAB AM Prep SUTAB PM Prep 2 Day CLNPrep

All Illinois Patient Prep Forms- Spanish

CLENPIQ AM Prep CLENPIQ PM Prep Capsule Instructions EGD Prep Flex Sig with Magnesium Citrate Prep Flex Sig without Magnesium Citrate Prep Magnesium Citrate Dulcolax Prep MiraLAX Prep NuLytely or GoLytely or TriLytely AM Prep NuLytely or GoLytely or TriLytely PM Prep PLENVU AM Prep PLENVU PM Prep SUPREP AM Prep SUPREP PM Prep SUTAB AM Prep SUTAB PM Prep 2 Day CLN AM Prep

General Procedure Prep Instructions

  • If you are pregnant, please discuss the risks and benefits of this procedure with your physician.
  • If you take anti-coagulants / blood thinners (for example: Coumadin, Plavix, Pradaxa, Xarelto, Eliquis, Effient, Brilinta, etc.) or Insulin, please notify our office at least 10 days prior to your procedure.
  • Please inform us if you weigh greater than 250 lbs., have kidney disease, congestive heart failure, artificial heart valves, a pacemaker or defibrillator (AICD), sleep apnea, or ascites.
  • Please discontinue iron or fiber supplements, seeds, nuts, popcorn, and raw vegetables one week before your colonoscopy.
  • Colonoscopies require a “Clear Liquid” diet as part of the preparation. Approved Clear Liquids:
    • Water, Black Coffee or Black Tea (no cream or artificial cream)
    • Strained fruit juices WITHOUT pulp (Example: apple, white grape)
    • Clear Broth or Bouillon (Example: chicken or beef or vegetable broth)
    • Carbonated CLEAR soft drinks (Example: Sprite, ginger ale)
    • Gatorade, Kool aid or lemonade with no pulp (NO RED OR PURPLE)
    • Plain Jell-O (without fruit or toppings) (NO RED OR PURPLE)
    • Popsicles (NO RED OR PURPLE)
    • NO DAIRY PRODUCTS
    • NO ALCOHOLIC BEVERAGES
  • FOR ANY PROCEDURE WITH ANESTHESIA
    • Do NOT use any tobacco products or marijuana, do NOT take non-prescribed drugs, and do NOT drink alcohol after midnight before your procedure.
  • Driving after your procedure:
    • Please make arrangements to have someone drive you to and from the designated location for your procedure.
    • You will not be allowed to use any form of public transportation following your procedure, which includes: Taxi, Bus, Ride-share service, Uber, Lyft and the like.
    • The test may be canceled if you do not have a driver, there will be no exceptions.
    • You will be under sedation during your procedure and will be unable to work, drive or operate heavy machinery the day of your procedure.