Date of colonoscopy:

DATE OF COLONOSCOPY:
_____________________
DATE OF BLOODWORK:
_____________________

FACILITY:
_____________________

SOMEONE MUST DRIVE YOU HOME FROM THE FACILITY THE DAY OF YOUR PROCEDURE !!!

**WE DO NOT HAVE PROCEDURE TIMES UNTIL THE DAY PRIOR TO YOUR SCHEDULED TEST**
If your procedure is at OCEAN MEDICAL CENTER, our office will call you the day prior with your procedure time. If you are
scheduled for a Monday, we will call you on the Friday before. If you do not hear from us the day prior by 3:00pm, please call
732.458.8300 ex 220 and ask for Lori and she will give you your procedure time. They are located at 425 Jack Martin Blvd, Brick, NJ
08724, 732.840.2200.
When reporting to OCEAN MEDICAL CENTER, please use the free parking garage for patients and visitors, UNLESS you would
like to use the free Valet Parking which is located on Jack Martin Blvd. Main Entrance (opened from 7am to 5pm Mon – Fri) to
report to the Same Day Surgery Unit, go to Parking Lot C (by the parking garage) go through the double glass doors and give the
receptionist your name and they will direct you where you need to be.
If your procedure is at SHORE OUTPATIENT SURGERY CENTER, that facility will call you the day before to inform you of your
procedure time. If you have not heard from them by 1:00pm, please call them at 732.942.9835. Their address is 360 Route 70,
Lakewood, NJ 08701. They are in the same parking lot with STS Tire, across from Charlie Brown Restaurant.
If your procedure is at SEASHORE SURGICAL INSTITUTE, that facility will call you the day before to inform you of your
procedure time. If you have not heard from them, please call 732.836.9800. They are located at 495 Jack Martin Blvd, Brick, NJ
08724.
If your procedure is at JERSEY SHORE AMBULATORY CARE CENTER, that facility will call you the day before to inform you of
your procedure time. If you have not heard from them, please call 732.776.4600. They are located at 1945 Route 33, Neptune NJ
07754. When reporting to JSACC, report to the second floor and give receptionist your name, they will direct you to where you need
to be.
If your procedure is at ADVANCED ENDOSCOPY AND SURGICAL CENTER, that facility will call you the day before to inform
you of your procedure time. If you have not heard from them, please call 732.935.0031.If your procedure is on a Monday, they will
call you on Friday. They are located at 142 Route 35, Suite 101, Eatontown, NJ 07724.
IF YOU HAVE ANY QUESTIONS ABOUT YOUR PROCEDURE, PLEASE CALL 732.458.8300 X 220 AND
ASK FOR LORI.

HOME INSTRUCTIONS FOR YOUR COLONOSCOPY

These instructions are to be followed the day prior to your scheduled procedure. Please follow them carefully.
**IF YOU TEND TO HAVE CONSTIPATION, THEN THE EVENING PRIOR TO YOUR COLONOSCOPY PREP_________,  
PLEASE TAKE TWO (2) DULCOLAX TABLETS (if Dulcolax is not available, you may purchase Senekot) THIS CAN BE 
PURCHASED OVER THE COUNTER. 
 
THE DAY PRIOR IS: ___________
The day prior to your Colonoscopy, starting at 7am in the morning until midnight the night before, you may have
unlimited amounts of Clear Liquids, NO SOLID FOODS, NO MILK OR MILK PRODUCTS.Please see below for
examples of clear liquids. DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT UNTIL AFTER YOUR
PROCEDURE IS COMPLETED.
UNLIMITED AMOUNT OF CLEAR LIQUIDS
• Clear fruit juices (apple, white grape, white cranberry etc) • Water (flavored water is ok) • Plain Jell-O (NOT RED or PURPLE) • Ice Pops (NOT RED or Purple) • Hard candy • All types of teas (hot or cold) • Clear sodas (7-up, ginger-ale, sprite, etc) • Gatorades (NO RED NO PURPLE) • Broth/Bouillon (Nothing Red or Purple) Æ NO Milk; NO Milk products; NO solid food

PLEASE DO NOT SUBSTITUTE THE ABOVE

AT 4:00 pm Drink (1) 10oz bottle of MAGNESIUM CITRATE (NOT RED)
AT 7:00 pm Drink (1) 10oz bottle of MAGNESIUM CITRATE (NOT RED)

AT 8:00 pm Take three (3) DULCOLAX TABLETS with 16oz of clear liquids. You need the laxative, not the

stool softener.
THE ABOVE LAXITIVES CAN BE PURCHASED AT YOUR FOOD STORE, DRUG STORE OR PHARMACY. REMEMBER NOTHING TO EAT OR DRINK AFTER MIDNIGHT IMPORTANT INFORMATION, PLEASE REVIEW AT LEAST ONE (1) WEEK PRIOR __________________________________________________________________________________________
FAILURE TO DO THE FOLLOWING COULD RESULT IN CANCELLATION AND/OR RESCHEDULING OF YOUR PROCEDURE. You should have informed the office if you are a Diabetic/if you are on Dialysis/have a defibrillator/ pacemaker/heart valve replacement/ history of heart valve infection/Mitro valve prolapse/or any recent changes in your medical history. Please stop taking aspirin, Iron supplements, Multi-Vitamins with Iron, arthritis medications, vitamin E
and Ginko Biloba seven (7) days prior to your scheduled colonoscopy. If you have not done this, please
call our office for reassurance. Tylenol may be taken if needed.
Please stop taking any blood thinners, (Coumadin/Plavix/Presantine) _________ days prior to your
procedure. (Please CHECK WITH THE PHYSICIAN THAT PRESCRIBES these to you; to obtain the medical
clearance to temporarily discontinue these meds prior to your procedure. If you have not done this, please call our office
PLEASE STOP TAKING ALL DIURETIC MEDICATIONS, (Lasix, Furosemide, Spironolactone,
Aldactone, Etc.) the day prior to your colonoscopy. If your Blood Pressure Medication Contains a
Diuretic, it is ok to take that.
DO NOT STOP TAKING YOUR HEART OR BLOOD PRESSURE MEDICATIONS PRIOR TO
YOUR PROCEDURE. YOU ARE INSTRUCTED TO TAKE THEM THE MORNING OF YOUR
PROCEDURE WITH A SIP OF WATER.
™ Please CALL YOUR INSURANCE COMPANY so you are aware of any costs that you
may be responsible for. All procedures are done on OUTPATIENT basis. It is ultimately the Patients responsibility to be familiar with your own individual personal insurance policy information/benefits.
WARNING **NO LIQUIDS** at least 3 hours prior to your procedure.
Liquids are NOT to be consumed within 3 hours prior to your arrival time for your procedure;
failure to heed this warning could result in cancellation of your procedure by the anesthesiologist
and/or the gastroenterologist.
Please be aware…DO NOT WEAR ANY JEWELRY TO YOUR PROCEDURE. The facility is not
responsible if these items are misplaced/lost.
*Please remember that someone MUST drive you home after your procedure.
Bring a list of current medications with you on the day of your procedure. If you have any questions or concerns, please do not hesitate to contact our office at
732.458.8300 x 220 and ask for Lori.

Source: http://www.atlanticcoastgastro.com/uploads/forms/MAG%20CITRATE.pdf