Submit the completed form via fax to (707) 303-2694 or bring it to your appointment at Digestive Care Center, 500 Doyle Park Drive, Suite 205, Santa Rosa, CA 95405. Ensure all sections are filled out accurately and completely. For any questions, contact us at (707) 303-8350.

For capsule endoscopy procedures in 2024 and 2025, schedule your exam with the Digestive Care Center at least two weeks in advance. Ensure you adhere to the preparation timeline outlined in the instructions, beginning 7 days before your exam date. If any changes are needed, notify the center at least a week prior to your appointment to avoid cancellation fees.

The purpose of this form is to provide patients with detailed instructions for preparing for a capsule endoscopy using the MiraLAX prep method. It ensures that patients follow a specific timeline and adhere to dietary and medication guidelines, ensuring a successful and accurate procedure. This form also serves as a reference for healthcare providers to guide and support patients throughout the preparation process.

• 1. Purchase Ingredients: This section lists the ingredients needed for the MiraLAX prep, including MiraLAX, Gatorade or other sports drink, and Simethicone chews or soft gels.
• 2. Dietary Guidelines: This section provides detailed dietary instructions for the days leading up to the procedure, including foods to avoid and liquid diet guidelines.
• 3. Medication Instructions: This section outlines which medications to discontinue before the exam and how to adjust diabetic medications.
• 4. Appointment Details: This section includes information on confirming the appointment, providing paperwork, and transportation considerations.
• 5. Post-Procedure Care: This section provides guidance on post-procedure diet and activities, including when to resume normal diet and checking for the capsule in stool.

If you fail to submit this form, you may experience delays or cancellations of your procedure. Lack of proper preparation can lead to inaccurate results.

• Procedure Delay: Failure to confirm the appointment or complete the prep on time may result in the procedure being rescheduled.
• Inaccurate Results: Not adhering to the preparation guidelines can lead to poor visibility during the procedure and inaccurate results.
• Cancellation Fees: If you change your appointment or fail to appear, you may be charged a cancellation fee of $150.00.

• 1. Scheduled Procedure: Use this form to prepare when you have an upcoming capsule endoscopy.
• 2. Doctor's Instructions: Use this form when instructed by your doctor to follow a specific preparation method.
• 3. Dietary and Medication Guidelines: Use this form to follow the necessary dietary and medication adjustments before the procedure.
• 4. Appointment Confirmation: Use this form to confirm your appointment and ensure all paperwork is completed.
• 5. Post-Procedure Care: Use this form to follow the post-procedure care instructions and resume normal activities.