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Gsm-kec.com

DIGESTIVE HEALTH ASSOCIATES OF SOUTHWEST MI, PC
DBA/Gastroenterology of Southwest Michigan

NAME:«Pt_Full_Name»

DATE: «Appt_Date»

ARRIVAL TIME: ______________________________

PROCEDURE: COLONOSCOPY
You have an appointment with «Appt_Prov_Full_Name» at the Kalamazoo
Endo Center.

The appointment time and date appear above.
Please register at the KEC registration desk at your arrival time at 3300 Cooley
Court.
Please be sure to bring your Photo ID & Insurance cards. You will be
asked for them when you check in.


Should any problems arise and you may need to cancel your appointment, or have
any questions, please call our office at (269) 349-2266 during the hours of 8:00
a.m. to 5:00 p.m.

YOU MUST BE ACCOMPANIED BY A RESPONSIBLE ADULT TO DRIVE YOU
HOME UPON DISCHARGE
It is critical that you follow these written instructions as directed not the instructions on
the prep box. Please stop eating all indigestible foods such as corn, seeds and popcorn
at least 5 days prior to your procedure.
A few days prior to your procedure
please confirm that you have received a
prescription for the 2 liters of HalfLytely. If you have not, please contact our
office at 269-349-2266.

How to prep for your procedure:
1) Take TWO (2) Dulcolax tablets two nights before your procedure.
2) Start a clear liquid diet the morning before your procedure.
3) Drink 2 liters of Halflytely solution over two (2) hours starting at 6:00 P.M.
4) Have nothing by mouth after____________. Because you will receive sedation for the procedure, you will need to avoid driving, drinking alcoholic beverages, operating machinery, using sharp instruments and making critical decisions.

Please bring a list of present medications and drug allergies
. If you are
allergic to latex products, please call our office as soon as possible so precautions
The liquids listed below are allowed during the preparation.
Consume nothing with red dye.
Reminder: The more you drink the better your prep will be
MEDICATIONS
Reduce the A.M. Dosage by ½ the morning of the procedure. or other anticoagulants. STOP (5) five days prior to the
procedure.
Please contact our office for instructions 269-349-2266.
STOP(7) Seven days prior to the procedure.
Please contact our office for instructions 269-349-2266.
DO NOT take day of the procedure.
STOP(2) Two days before the procedure.
Take ½ the night before the procedure, and none the **All other medications may be taken as directed**
Concerning multiple bills in conjunction with your procedure:
Please take note: When an outpatient procedure is performed at a facility you will receive
billings from the facility AND the physician. ALSO, if pathology is done you will receive
billings from Bronson or Borgess for handling the specimen AND from the pathologist
for processing and reading.

Some insurance’s require pre-certification for inpatient and outpatient procedures.
The procedure you are scheduled for is an outpatient procedure. Please check
with your insurance carrier to determine if you need pre-certification. If
you do not obtain pre-certification and your insurance requires it, the cost of this
procedure may become your financial responsibility. Thank you

Source: http://www.gsm-kec.com/Portals/0/docs/Forms/RISKKC.pdf

refreshdental.com.au

CONFIDENTIAL INFORMATION: Surname: ____________________________ First Name: __________________________ Date of Birth: _________________________ Home Address: ____________________________________________________________ ____________________________________________________________ Postal Address: ____________________________________________________________ Home Ph: ____________________

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