Colonoscopy, Suprep Instructions

IMPORTANT: Please read this now to be prepared for your procedure. If you have any questions, or need to
cancel or postpone your appointment, please call us at 617-754-8888.

Where to report for your procedure: Day/ Date: ____________________________

Boston Endoscopy Center Arrival Time: __________________________

175 Worcester Street Procedure Time: _______________________

Route 9 Westbound
¼ mile west of Rt. 128/95 Approximate discharge time: _____________
Wellesley, MA 02481
Parking is free Doctor who will do your test:

Scheduling Phone: 617-754-8888 ______________________________________

Advance preparation for your procedure

 Medications – If you take Pepto-Bismol or any iron supplement, please stop taking 7 days prior to your
procedure. You can continue to take aspirin or similar pain medicines. If you take blood-thinning medicine,
please call our scheduling office if you did not discuss it when you booked the appointment. Do NOT make
any changes to these medicines on your own.
 Diabetes – Please contact the doctor who manages your diabetes before making any changes to your diet,
medications or insulin pump.
 If you may be pregnant – Please consult your OB/GYN doctor prior to your appointment to discuss optimal
timing for your procedure, and the best sedation/anesthesia approach.
 Sedation – Please let us know in advance about any of the following items, which could have an impact on any
sedation you may receive:
• Allergic reaction or other problems related to sedatives or pain medicine/narcotics
• If your weight is over 300 pounds
• You are currently taking narcotic pain medicine
• You have severe liver disease
 As you recover from the sedatives, do not go back to work or school, make important decisions or provide care
for children. You may resume all activities the next day unless otherwise instructed.

 ARRANGE A RIDE HOME– A responsible adult must come into the center when you are ready for discharge
and accompany you home. No exceptions are made. You may not drive yourself home after sedation.

 For more information, check out the Preparing for your Procedure page
on our website by scanning this code with the camera on your phone
or visiting www.bidmc.org/gipreps

1
Colonoscopy bowel prep: Suprep
IMPORTANT!

Preparation Check List Please read all instructions

at least one week prior to
your procedure and call our
Three (3) days before your colonoscopy office if you have any
 Begin a low-residue diet. See the enclosed fact sheet for a guide to questions.
which foods you should avoid.

The day before your colonoscopy

 Begin a clear liquid diet as soon as you wake up. Be sure to drink What you will need
plenty of clear liquids throughout the day. See the fact sheet for a
list of clear liquids.  Bowel Suprep Kit from your pharmacy

 7 pm – Suprep dose #1: You must complete Steps 1-4 before Optional:
going to bed.  Three (3) bottles (16 oz. each) of clear
 STEP 1: Pour one 6-ounce bottle of Suprep liquid into the mixing liquid or sports drink (except red or pink)
 Packets of Jell-O – any color except red
container.
or pink
 STEP 2: Add cool drinking water to the 16-ounce line on the  Vegetable, chicken, or beef bouillon
container and mix. (Note: Dilute the solution concentrate as broth cubes
directed on the packaging prior to use.)  Baby wipes
 STEP 3: Drink all the liquid in the container.
 STEP 4: Drink two more 16-ounce containers of clear liquid over ***Note: Medication taken by
the next hour. mouth may not be absorbed
properly when taken within 1
The day of your colonoscopy
hour before the start of each
 6 hours before your scheduled procedure time –
dose of Suprep.
Suprep dose #2: Drink the second 6-ounce bottle of Suprep,
following the same 4 steps as last night (above).
Prep Tips
We realize you may need to wake up in the middle of the night to
take the second dose. However, we have found this method results • If you feel nauseated while doing
in the cleanest colon. Even though your stools may become clear the prep, peppermint tea or
after the first dose, it is important to take the full second dose. sucking on a lemon may help.
• It also may help to put the prep
 4 hours before your scheduled procedure time: Stop drinking solution on ice.
all fluids. You may take any usual morning medications with a • When you begin to have diarrhea,
small sip of water. If you have diabetes or take blood thinners, baby wipes may be used to
please follow your doctor’s advice regarding any changes to your prevent irritation. Avoid using
medications that may be needed. Vaseline jelly or Desitin.

2
 Low-residue and clear liquid diets IMPORTANT!
Below is a guideline of foods you can eat while A low residue diet will help you
following a low-residue diet before your procedure, as get the best results from your
well as a list of clear liquids for that stage of the prep. In bowel prep. If you aren’t sure if a food is
general, avoid anything tough or fibrous, and anything low-residue, it is best to skip it while
with whole grains, nuts, seeds, skins or red dye. you are preparing for your procedure.

Food group Foods allowed Foods to avoid

Milk, soy or nut milks (as long as they No dairy product with pieces of nuts, seeds
Milk & Dairy aren't gritty) ice cream, yogurt, cheese or fruit in it
Coffee, tea, soda, juices with no pulp, Kool- No drinks with pulp, seeds, added fiber or
Beverages Aid (without red dye), Boost, Ensure or other prune juice
nutritional supplements without added fiber
Any refined breads including English No whole grains, oatmeal, granola,
Breads, cereals muffins, pita, biscuits, muffins, crackers, anything with seeds or nuts, corn bread,
pancakes, waffles, Cheerios, Cornflakes, graham crackers, brown or wild rice,
& starches Rice Krispies, white rice, refined pastas potato skins, quinoa
Canned or cooked fruit without skins No raw fruits (except ripe bananas), canned
Fruits or seeds, apple sauce, ripe bananas, pineapple, oranges, mixed fruit, dried fruit,
jellied cranberry sauce whole cranberry sauce, avocado
Tender, well-cooked canned or frozen No raw vegetables or any cooked that are
Vegetables vegetable with no seeds or skins, such as tough or fibrous such as broccoli,
peeled carrots or beets, strained vegetable asparagus, spinach, etc.
juice or tomato sauce
Cooked tender fish, poultry, beef, pork, No gristle, cold cuts or sausages, any meat
Meat & meat eggs, tofu, smooth nut butters substitute made with whole grains, seeds or
substitutes pieces of nuts, beans, peas or lentils

Salt, sugar, ground or flaked spices, No pepper, seed spices or other seeds,
chocolate, any liquid or smooth condiment nuts, popcorn, pickles, olives
Miscellaneous such as ketchup, soy sauce, mayo or jelly
(but not jam or preserves)

Clear Liquid Diet: Stay hydrated and drinks lots of clear liquids throughout the day!
When you reach the clear liquid stage of your prep, No solid foods. No hard candy or gum, no drinks with
you may only have: water; light-colored sodas; tea or red dye, no dairy, no juices with pulp, no alcohol.
coffee (black only- no cream or milk); clear juices,
Gatorade or other sports drinks (no red dye) chicken,
beef, and vegetable broths; bouillon; Jell-O (no red
Jell-O); and popsicles (no red popsicles).
3
 Boston Endoscopy Center
Patient’s Rights and Notification of Physician Ownership

EVERY PATIENT HAS THE RIGHT TO BE TREATED AS AN INDIVIDUAL AND TO ACTIVELY PARTICIPATE IN AND MAKE INFORMED
DECISIONS REGARDING HIS/HER CARE. THE FACILITY AND MEDICAL STAFF HAVE ADOPTED THE FOLLOWING PATIENT RIGHTS AND
RESPONSIBILITIES, WHICH ARE COMMUNICATED TO EACH PATIENT OR THE PATIENT’S REPRESENTATIVE/SURROGATE PRIOR TO
THE PROCEDURE/SURGERY.

PATIENT’S RIGHTS:
Every patient of a facility shall have the right:
 Upon request, to obtain from the facility in charge of his care the name and specialty, if any, of the physician or other
person responsible for his care or the coordination of his care;
 To confidentiality of all records and communications to the extent provided by law;
 To have all reasonable requests responded to promptly and adequately within the capacity of the facility;
 upon request, to obtain an explanation as to the relationship, if any, of the facility to any other health care facility or
educational institution insofar as said relationship relates to his care or treatment;
 To obtain from a person designated by the facility a copy of any rules or regulations of the facility which apply to his
conduct as a patient;
 Upon request, to receive from a person designated by the facility any information which the facility has available relative
to financial assistance and free health care;
 Upon request, to inspect his medical records and to receive a copy thereof in accordance with section seventy, and the
fee for said copy shall be determined by the rate of copying expenses, except that no fee shall be charged to any
applicant, beneficiary or individual representing said applicant or beneficiary for furnishing a medical record if the record
is requested for the purpose of supporting a claim or appeal under any provision of the Social Security Act or federal or
state financial needs-based benefits program, and the facility shall furnish a medical record requested pursuant to a claim
or appeal under any provision of the Social Security Act or any federal or state financial needs-based program within
thirty days of the request; provided however, that any person for whom no fee shall be charged shall present reasonable
documentation at the time of such records request that the purpose of said request is to support a claim or appeal under
any provision of the Social Security Act or any federal or state financial needs-based program;
 To refuse to be examined, observed, or treated by students or any other facility staff without jeopardizing access to
psychiatric, psychological, or other medical care and attention;
 To refuse to serve as a research subject and to refuse any care or examination when the primary purpose is educational
or informational rather than therapeutic;
 To privacy during medical treatment or other rendering of care within the capacity of the facility;
 To be informed of their right to change providers if other qualified providers are available.
 To prompt life-saving treatment in an emergency without discrimination on account of economic status or source of
payment and without delaying treatment for purposes of prior discussion of the source of payment unless such delay can
be imposed without material risk to his health, and this right shall also extend to those persons not already patients of a
facility if said facility has a certified emergency unit;
 To informed consent to the extent provided by law;
 Upon request to receive a copy of an itemized bill or other statement of charges submitted to any third party by the
facility for care of the patient or resident and to have a copy of said itemized bill or statement sent to the attending
physician of the patient or resident;
 If refused treatment because of economic status or lack of a source of payment, to prompt and safe transfer to a facility
which agrees to receive and treat such patient. Said facility refusing to treat such patient shall be responsible for:
ascertaining that the patient may be safely transferred; contacting a facility willing to treat such patient; arranging the
transportation; accompanying the patient with necessary and appropriate professional staff to assist in the safety and
comfort of the transfer, assure that the receiving facility assumes the necessary care promptly, and provide pertinent
medical information about the patient’s condition; and maintaining records of the foregoing.

4
 PATIENT RESPONSIBILITIES:

 To provide complete and accurate information to the best of their ability about their health, any medications, including
over-the-counter products and dietary supplements and any allergies or sensitivities.
 To follow the treatment plan prescribed by their provider, including pre-operative and discharge instructions.
 To provide a responsible adult to transport them home from the facility and remain with them for 24 hours, if required by
their provider.
 To inform their provider about any living will, medical power of attorney, or other advance healthcare directive in effect.
 To accept personal financial responsibility for any charges not covered by their insurance.
 To be respectful of all healthcare professionals and staff, as well as other patients.

If you need an interpreter:

If you will need an interpreter, please let us know and one will be provided for you. If you have someone who can translate confidential, medical
and financial information for you please make arrangements to have them accompany you on the day of your procedure.
Rights and Respect for Property and Person Privacy and Safety
The patient has the right to: The patient has the right to:
• Exercise his or her rights without being subjected to discrimination or reprisal. • Personal privacy
• Voice a grievance regarding treatment or care that is, or fails to be, furnished. • Receive care in a safe setting
• Be fully informed about a treatment or procedure and the expected outcome before it is performed • Be free from all forms of abuse or harassment
• Confidentiality of personal medical information.
Statement of Nondiscrimination:
Boston Endoscopy Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin,
age, disability, or sex.
Boston Endoscopy Center cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad,
edad, discapacidad o sexo.
Boston Endoscopy Center respecte les lois fédérales en vigueur relatives aux droits civiques et ne pratique aucune discrimination basée sur la race,
la couleur de peau, l'origine nationale, l'âge, le sexe ou un handicap.
Boston Endoscopy Center 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、年齡、殘障或性別而歧視任何人。

Advance Directives

An “Advance Directive” is a general term that refers to your instructions about your medical care in the event you become unable
to voice these instructions yourself. Each state regulates advance directives differently. STATE laws regarding Advanced
Directives are found in Massachusetts Statutes chapters 111 §3 and 201D§1. In the State of Massachusetts, all patients have a
right to name someone they know and trust to make healthcare decisions for them. If, for any reason and at any time, they
become unable to make or communicate those decisions, the Health Care Proxy is a legal document used to make their wishes
known. It is an important document, however, because it concerns not only the choices they make about their health care, but
also the relationships they have with their physician, family, and others who may be involved with their care.
You have the right to informed decision making regarding your care, including information regarding Advance Directives and this
facility’s policy on Advance Directives. Applicable state forms will also be provided upon request. A member of our staff will be
discussing Advance Directives with the patient (and/or patient’s representative or surrogate) prior to the procedure being
performed. https://malegislature.gov/Bills/188/House/H1888

Boston Endoscopy Center respects the right of patients to make informed decisions regarding their care. The Center has adopted the position that
an ambulatory surgery center setting is not the most appropriate setting for end of life decisions. Therefore, it is the policy of this surgery center that
in the absence of an applicable properly executed Advance Directive, if there is deterioration in the patient’s condition during treatment at the surgery
center, the personnel at the center will initiate resuscitative or other stabilizing measures. The patient will be transferred to an acute care hospital,
where further treatment decisions will be made.
If the patient has Advance Directives which have been provided to the surgery center that impact resuscitative measures being taken, we will discuss
the treatment plan with the patient and his/her physician to determine the appropriate course of action to be taken regarding the patient’s care.

5
Complaints/Grievances: If you have a problem or complaint, please speak to one of our staff to address your concern. If necessary, your problem
will be advanced to center management for resolution. You have the right to have your verbal or written grievances investigated and to receive written
notification of actions taken.
The following are the names and/or agencies you may contact:
Jessica McDermott, Center Leader
Boston Endoscopy Center
175 Worcester Street
Wellesley Hills, MA 02481-5514

You may contact the state to report a complaint;

Massachusetts Department of Public Health
250 Washington Street, 6th Floor
Boston, MA 02108
Phone: 617.624.6000

State Web site: http://www.mass.gov/eohhs/gov/departments/dph/

Medicare beneficiaries may also file a complaint with the Medicare Beneficiary Ombudsman. Medicare Ombudsman Web site:
http://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html

Medicare: www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227)

Office of the Inspector General: http://oig.hhs.gov

This facility is accredited by the Accreditation Association for Ambulatory Health Care (AAAHC). Complaints or grievances may also
be filed through:
AAAHC
5250 Old Orchard Road, Suite 200
Skokie, IL 60077
Phone: 847-853-6060 or email: [email protected]

Physician Ownership
Physician Financial Interest and Ownership: Physician Financial Interest and Ownership: The center is owned, in part, by the
physicians. The physician(s) who referred you to this center and who will be performing your procedure(s) may have a financial and
ownership interest. Patients have the right to be treated at another health care facility of their choice. We are making this
disclosure in accordance with federal regulations.

THE FOLLOWING PHYSICIANS HAVE A FINANCIAL INTEREST IN THE CENTER:

Harry Anastopoulos Douglas Horst

Laurence Bailen Elissa Kaplan
Catherine Cheney Dennis Lee
Richard Curtis Anthony Lembo
George Dickstein Benjamin Levitzky
Steven Fine Douglas Pleskow
Katharine Germansky Sunil Sheth

6
Boston Endoscopy Center
175 Worcester Street
Wellesley Hills, MA 02481
(617) 754-0800

INFORMED CONSENT

1. I give my permission to __________________, MD to perform a Colonoscopy (an examination of my lower

gastrointestinal tract.)

2. I understand that during this procedure, new findings or conditions may appear that could require additional
treatments.

3. _____________________, MD has discussed the items listed below with me, including, but not limited to the
following:

a. Reason for procedure:_____________________________________________________________

b. Benefits and risks of this procedure and of conscious sedation:

These general risks include, but are not limited to: bleeding, blood clots, tissue damage, perforation, pain,
infections, missed polyps or cancer, drug reaction, brain damage, and even loss of body function or life.
Some complications may lead to hospitalization, surgery, or the need for blood transfusion or other
treatments. I realize that these risks may occur in connection with the particular procedure proposed to
me:

_________________________________________________________________________________

c. The alternatives to this procedure and what could happen if nothing were done.

4. I know that other unexpected risks or complications not discussed may occur and that there is no guarantee about
the results of the procedure.

5. I understand that in the event of a complication I may be transferred to an acute care facility if my physician feels it is
necessary.

6. I know that the clinical staff may help my doctor during my procedure.

7. Any tissue removed may be examined and disposed of by the center in accordance with standard practice.

8. I understand that my procedure may be photographed or videotaped.

9. I understand my doctor’s explanation and all of my questions have been answered completely.

10. My signature below acknowledges that I consent to the performance of the procedure described above.

11. I impose no specific limitations or prohibitions regarding treatment other than the following.
________________________________________________________________________

________________________________________________ ________________ ______

Patient (or responsible person) DATE TIME

________________________________________________ ______________ ________

____________________MD. DATE TIME

7
 Please complete your SA survey 24 hours prior to your
appointment
Boston Endoscopy Center offers patients the convenience and privacy of a secure,
online registration process. If you are a new patient to our center, please go online
today to complete your registration using the login information below. You will be
asked about your health history, medications, and previous surgeries. If you are a
returning patient, please update your online form. It’s important to complete or update
your online registration as soon as possible so that your medical team will have time to
review your information prior to your visit. We will call you if we have any questions or
concerns. We look forward to seeing you soon!

New Patients Date - ______________________

Procedure - _________________
1. Go online to:
bostonendoscopycenter.com Surgeon - ___________________
2. Go to: “Patients Start Here”
Please complete your online questionnaire as
3. Enter the following password: soon as possible. A nurse will call you if
BEC617NEW necessary.

Returning Patients
If you received an email with login instructions:
1. Click the web page link in the email. You will be redirected to a login page.
2. At the login page, your Access Token will be entered automatically.
3. Enter your date of birth using the “MM/DD/YYYY” format.
4. After entering your Date of Birth, click “Resume”. You can then review and modify
your most recent health history form.

If you printed or saved your login instructions:

1. Go online to: simpleadmit.com
2. Follow the link: “Patients Start Here.”
3. Enter your secure Access Token that you saved or printed.
4. Enter your date of birth using the “MM/DD/YYYY” format.
5. After entering your Access Token and Date of Birth, click “Resume”. You can then
review and modify your most recent health history form.
*Please note, you would only have the Access Token if you have previously completed the online pre-
admission form and either printed or saved your Access Token or entered your e-mail address requesting
that the token be emailed to you. The token is sent to the e-mail address you provided. If you no longer
have your Access Token, please contact the facility at (617) 936-7693.