SJN GI-MIRALAX +DULCOLAX Rev. 9.13.2023
Issued Date: ______________
Colonoscopy Preparation Instructions
MIRALAX + Dulcolax (Over-The-Counter)
Thank you for choosing St. Joseph Hospital!
Date:___________ Arrival Time:_____________ Dr._______________
*You may be contacted by the Endoscopy Department the day of your procedure to adjust your arrival time.
Location: 172 Kinsley Street, Nashua, NH – Main Lobby, 2
nd
Floor Endoscopy Department
Pre-registration is required one week prior to your procedure. To pre-register, or if you have any questions
about cost of coverage, please call 866-620-4781.
If you have any questions regarding your prep or procedure or, if for any reason you need to reschedule your
procedure, please call 603-578-9363.
• Call and check with your insurance company directly as soon as possible to determine if your procedure
will be covered.
• If you had a colonoscopy in the past with an inadequate prep, call our office as soon as possible since your
prep may change.
• If you develop a fever, cough, or any cold/flu like symptoms: or have any outstanding cardiac or
respiratory testing, you MUST call us to reschedule.
• Due to the anesthesia that will be administered during your procedure, it is required that you have a
responsible adult or person of legal driving age to drive you home after your procedure. You cannot drive
or walk. You cannot take a taxi/Uber unless you are accompanied by a responsible adult. We fully expect
you will be able to return to your normal activities the day after your procedure. We will unfortunately
have to cancel your procedure if you fail to have a ride home available.
• If you need assistance with transportation: Gentle Care Ride offers medical transportation for a fee and
services most of the Southern and Central New Hampshire Region. They can be reached by calling 603-
341-1720 (they require at least two days’ notice; however, please call early due to availability).
pg. 1
Plan Ahead
SJN GI-MIRALAX +DULCOLAX Rev. 9.13.2023
We strongly encourage you to check your benefit coverage by calling your insurance company directly
before any procedure is performed to find out what your benefits are.
• Estimates for procedures can be provided by calling 866-620-4781.
• The standard CPT code for a colonoscopy is 45378 for both screening and diagnostic colonoscopies.
• If a biopsy is required or if a polyp is removed during your screening procedure, your insurance benefit may
change.
• Your benefit coverage might also vary based upon the location of your procedure. If your insurance has
trouble finding St. Joseph Hospital Nashua in their directory, our Tax ID number is: 02-0222215.
• If you are having an upper endoscopy (EGD) procedure in addition to your colonoscopy, please check with
your insurance about coverage. The CPT code for an upper endoscopy (EGD) is 43235.
Anesthesia Fees - Anesthesia for SJH is provided by Narragansett Bay Anesthesiology: 401-632-4464.
• Certain insurances may have restrictions on the coverage of anesthesia. We encourage you to review your
individual benefits.
PLEASE CALL YOUR MANAGING OR PRESCRIBING PHYSICIAN IF:
• You take blood thinners such as Coumadin (Warfarin), Apixaban (Eliquis), Plavix (Clopidogrel),
Aggrenox, Ticlid (Ticlopidine), Pradaxa (Dabigatran), Effient (Prasugrel), Brilinta (Ticagrelor) or
Xarelto for instructions on stopping these. Please do not stop taking your blood thinner without talking
to your managing/prescribing physician.
• You are receiving Lovenox injections. These must be stopped 24 hours prior to your procedure.
• You have Diabetes, to discuss your diabetes medications.
• If you take any of the medications listed below only for weight loss on a DAILY basis, hold the
medication for 24 hours prior to your procedure. If you take any of the medications listed below
only for weight loss on a WEEKLY basis, hold 1 week prior to your procedure.
• Dulaglutide (Trulicity), Exenatide extended release (Bydureon bcise), Exenatide (Byetta), Semaglutide
(Ozempic), Liraglutide (Victoza, Saxenda), Lixisenatide (Adlyxin), Semaglutide (Rybelsus)
GI cannot advise you on the adjustment of your other medications. Please call your managing or
prescribing physician if you have questions about your prescribed medications.
pg. 2
Medications
Insurance Information
SJN GI-MIRALAX +DULCOLAX Rev. 9.13.2023
• Miralax: (1) 238g bottle and (1) 119g bottle of Polyethylene Glycol 3350 (Miralax or generic).
• Dulcolax (stimulant laxative): (4) 5mg tablets (any brand is fine).
• Baby wipes/skin barriers (if desired)
• Gatorade/Sports Drink/Approved Clear Liquid: (1) 64 oz bottle and (1) 32 oz bottle. Any flavor is
fine EXCEPT FOR RED, ORANGE, or PURPLE in color.
• Purchase prep items ahead of time, if possible.
• STOP oral iron supplements (not infusions), multivitamin w/iron, fish oil, vitamin E.
• Begin a low-fiber diet. Avoid any foods with seeds, peels, nuts, salads, and raw vegetables.
ALLOWED
AVOID
Meats (beef, pork, poultry-without skin) and fish
Whole wheat or whole-grain breads, cereals or
pastas
White bread without seeds or nuts
Brown or wild rice, oats, kasha, barley, quinoa
White rice, White pasta, crackers
Dried fruits and prune juice
Pancakes and waffles
Fruits with seeds, skins, or membranes (grapes,
oranges, berries)
Cooked and peeled carrots, potatoes, seedless
squash, veggie noodles without skins
Raw or undercooked vegetables and salads (corn,
lettuce, brussels sprouts, spinach)
Fruits without skins, seeds, or membranes (melons,
bananas, peeled apples, peeled canned fruits)
Beans, peas, and lentils
Milk and foods made from milk, milk substitutes
Seeds and nuts, and foods containing them (peanut
butter and other nut butters)
Butter margarine, oils and salad dressings without
seeds
Popcorn
pg. 3
Prep Items to Purchase
7 Days Before Your Colonoscopy
SJN GI-MIRALAX +DULCOLAX Rev. 9.13.2023
It is very important to follow these timing instructions even if you may have to wake up in the middle of the
night. If you complete the prep too early, fluid from your digestive system can build back up which will affect
the quality of your procedure.
Before 10AM - You can have a LIGHT breakfast.
After 10AM – NO SOLID FOODS, NO FULL LIQUIDS, NO DAIRY PRODUCTS, OR ALCOHOL.
Remain on a clear liquid diet only.
ALLOWED
Water
Black coffee/ tea (no milk, creamer)
Clear juices that are not red, orange, or purple
Clear broths
Popsicles
Jell-O
Coconut water
Starting at 5PM
• Mix the 238gm bottle of Polyethylene Glycol 3350 (Miralax) powder, into a 64 oz bottle of
Gatorade/sports drink/approved clear liquid and drink slowly over a 2 ½ hour period.
• Bowel movements may be delayed. They may take time to start. Moving around helps.
• Nausea is a common occurrence. Try to tolerate as much as possible. Vomiting is rare, but it does
happen and is okay as long as you take as much as possible with lots of fluids.
Starting at 8PM – Take (4) 5mg Dulcolax tablets.
pg. 4
Day Before Your Colonoscopy
SJN GI-MIRALAX +DULCOLAX Rev. 9.13.2023
Please continue to remain on a clear liquid diet only. No solid food/full liquids are allowed.
5 HOURS PRIOR TO ARRIVAL:
• Mix 119 gm bottle of Miralax (polyethylene glycol 3350) powder, into a 32oz Gatorade/sports
drink/approved clear liquid and drink slowly within 1 hour.
• May drink clear liquids only* (see list of clear liquids).
• May brush teeth
• Upon arrival stool should be clear/yellow, any extra fluid will be suctioned during the procedure.
4 HOURS PRIOR TO ARRIVAL: ABSOLUTELY NOTHING BY MOUTH - NO gum; candy; mints;
smoking, water. May use Chap Stick for dry lips.
The ONLY MEDICATIONS you may take this morning three (3) hours prior to your appointment are:
o Cardiac (heart)
o Seizure
o Blood Pressure
o Asthma medications and inhalers
pg. 5
Morning of Your Colonoscopy
SJN GI-MIRALAX +DULCOLAX Rev. 9.13.2023
We ask that you please bring these items with you: Completed endoscopy health history form (last page of
the packet), the name and phone number of your ride, inhalers, CPAP/BiPAP (if easily transportable), glasses
(do not wear contacts), if menstruating can use a tampon, reading material or other items in case of unforeseen
delays, a copy of your medication list with dosing and the last time taken (including over the counter
meds).
Please DO NOT BRING: Any valuables, including jewelry. If you wear dentures, please do
not use denture adhesive on the day of your procedure, as they may need to be removed.
Before the start of your procedure, you will have the opportunity to discuss the procedure with your
gastroenterologist and the anesthesiologist regarding sedation. They will each explain the nature of the procedure,
and its risks, benefits, and alternatives. You will be asked to sign a consent form that you understand and agree
to the care.
Please expect to be at the hospital for about 2 ½ to 3 hours. We make every effort to remain on time, but delays
may occur.
You will need to rest for the remainder of the day. Do not operate any machines or motor vehicles.
You will receive a letter explaining your results approximately 2 to 3 weeks after your procedure.
pg. 6
Colonoscopy Day Expectations
SJN GI-MIRALAX +DULCOLAX Rev. 9.13.2023
ST. JOSEPH HOSPITAL ENDOSCOPY
YOUR NAME _______________________________
DRUG or FOOD ALLERGIES :  No  Yes please list _____________________________________
Personal Medical History: Please check all that apply and list any additional medical information below____
 High Blood Pressure
 High Cholesterol
 Anemia
 Heart Attack
 Heart Problem*
If yes describe:
__________________
 Sleep Apnea
CPAP__ BIPAP___
 Snores at night
COPD
Asthma
GERD/Heartburn
Stroke TIA
 Seizures
 Back Pain/injury
 Cancer,
type_________
 Diabetes
 Low Thyroid
High Thyroid
 Liver Disease
 Kidney Disease
 Bleeding Problems
 Falls in the past year
 Dentures Upper / lower/
Partial (please circle)
Surgery:
 Appendectomy
Gallbladder
 Hysterectomy
 C-Section
 Hernia
 Tonsillectomy
 Heart
 Abdominal Surgery
 Eye Surgery
Other:
 Pacemaker/Defibrillator
 Joint Replacement, location_________
 Other:
When did you DRINK FLUIDS last, including your Prep: ________________
Do you have any metal in your body (not teeth)?  No  Yes If yes where?________________
Females - Last Menstrual Period: __________ Any chance you could be pregnant?  No  Yes
Community Health Question- (unrelated to your procedure!) – Have you completed a living will or health
care proxy? This is a formal document naming someone to make decisions for you if you are unable to do so.
 Yes  No If no would you like more information?  Yes  No
If you have a list of your medications, please just GIVE it to the nurse - **DO NOT COMPLETE BELOW**
INCLUDE over the counter medications and herbals PLEASE.
Medication
Dose
How Often
Last Dose
Medication
Dose
How Often
Last Dose
Name of person taking you home today? Phone Number ____
What Items do you have with you TODAY for the procedure? If you have any of these walking in, we want to
ensure you have them walking out! Keep valuables at home please. Circle all that apply
Dentures: full partial upper lower Glasses Hearing aids Cane Walker
Personal Wheelchair Other:__________