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SANTA BARBARA
GASTROENTEROLOGY CONSULTANTS
MEDICAL GROUP
Name: __________________________ Facility: ☐ Santa Barbara Endoscopy Center
☐ Santa Barbara Cottage Hospital
Procedu x
e Date: _________________ Check In Time: __________________ ☐ Santa Ynez Cottage Hospital
COLONOSCOPY PREPARATION SHEET: GOLYTELY/ DULCOLAX 5 Days Prior
4 Days Prior
3 Days Prior
2 Days Prior
One Day Prior
Colonoscopy Day
☐ Arrange a
☐ Drink AT LEAST ☐ Drink AT LEAST 8 glasses of ☐ Beginning at 4 hours before your
colonoscopy, drink Golytely–8
ounce glass every 15 minutes until
four glasses have been ingested
☐ Follow a strict clear liquid diet
pharmacy with CANCEL
☐ After the last dose of Golytely,
do not eat or drink anything. You
☐ Take 1 Dulcolax 5 mg tablet at
BUT AVOID:
- Raw fruits
☐ After bowel movement occurs
☐ Confirm your - Raw vegetables
(or no later than 5pm), drink 8
- Nuts or popcorn
oz. glass of Golytely every 15
- Foods with small
minutes until four glasses have completed
seeds such as
been ingested
☐ If no BM occurs by 8 pm,
continue drinking one 8 oz.
glass of Golytely every 15
minutes until you have had a
BM or until 8 glasses have been
ingested
☐ Verify that patient questionnaire - Insurance Card Consider stopping all casual (not Dr. recommended) Aspirin or NSAIDS-no ibuprofen, Advil, Aleve, naproxen, Excedrin---only Tylenol is okay SANTA BARBARA
GASTROENTEROLOGY CONSULTANTS
MEDICAL GROUP
Notes and Suggestions
Directions for Facilities
“Clear fluids” means liquids that you can hold up to the light and see
Santa Barbara Endoscopy
through. Examples: Juices without pulp, sodas, coffee, tea, Jell-O, broth,
Center is at 25 W. Micheltorena
Gatorade and similar sports drinks. NO RED OR PURPLE
Use the Golytely preparation solution as per the written directions on the Diarrhea will occur during the preparation. Stay at home near the bathroom Santa Barbara Cottage
Irritation at the anal canal may occur. Vaseline applied to the skin around the Hospital admitting office is in the
anus may protect from burning later during the prep. YOU MAY NOT DRIVE HOME AFTER THE PROCEDURE. You are
advised not to drive the entire day. A responsible adult must accompany you home, even if you are taking a taxi or bus. Your procedure will be canceled if you have not made appropriate arrangements Post Procedure instructions will be given to you at the facility when you are Santa Ynez Cottage Hospital

Source: http://www.santabarbaragi.com/pdf/golytely_dulcolax_prep.pdf