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GASTROINTESTINAL SPECIALISTS
Aria Torresdale Medical Office Bldg. Barix Clinic
3998 Red Lion Rd S.242 280 Middletown Blvd
Philadelphia, Pa 19114 Langhorne, Pa 19047
215-632-3500 215-702-7090

UPPER GASTROINTESTINAL ENDOSCOPY PREPARATION YOU ARE SCHEDULED FOR A GASTROSCOPY ON ____________________ DO NOT TAKE ANY FOOD OR LIQUID BY MOUTH AFTER MIDNIGHT THE NIGHT BEFORE YOUR PROCEDURE. YOU MAY TAKE MEDICATIONS FOR BLOOD PRESSURE AND THE HEART WITH A SIP OF WATER THE MORNING OF THE PROCEDURE. ANY DENTURES MUST BE REMOVED BEFORE THE PROCEDURE. IT IS VERY IMPORTANT THAT YOU ARRANGE TO HAVE SOMEONE DRIVE YOU HOME AFTER THE PROCEDURE, AND THAT YOU DO NOT WORK OR DRIVE FOR THE REMAINDER OF THE DAY. PATIENTS ARRIVING WITHOUT A RIDE WILL HAVE THEIR PROCEDURE RESCHEDULED. IF YOU TAKE ANY BLOOD THINNING MEDICATIONS (ASPIRIN, ECOTRIN, ADVIL OR MOTRIN ETC.) ANTIPLATELET (COUMADIN, AGGRENOX, PLAVIX) OR ARTHRITIS MEDICINES (VIOXX, CELEBREX), PLEASE NOTIFY YOUR DOCTOR OR CARDIOLOGIST. THESE MEDICATIONS MUST BE STOPPED FOR 5 YO 7 DAYS PRIOR TO THE PROCEDURE. IF YOU HAVE ANY QUESTIONS, PLEASE CALL OUR OFFICE AT: **IT IS EXTREMELY IMPORTANT THAT YOU BRING ALL PRESCRIPTION
MEDICATION BOTTLES, YOUR INSURANCE CARD AND ANY CO-PAYS/CO-
INSURANCES WITH YOU ON THE DAY OF YOUR PROCEDURE**
GASTROINTESTINAL SPECIALISTS
Aria Torresdale Medical Office Bldg. Barix Clinic
3998 Red Lion Rd S.242 280 Middletown Blvd
Philadelphia, Pa 19114 Langhorne, Pa 19047
215-632-3500 215-702-7090

IMPORTANT INFORMATION REGARDING YOUR INSURANCE
Dear Patient:
Should your doctor determine that you require a diagnostic endoscopy
(upper endoscopy and/or colonoscopy); your procedure will be performed
in the Gastrointestinal Specialists Ambulatory Surgical Center. The
Ambulatory Surgical Center is approved by Medicare, licensed by the
Commonwealth of Pennsylvania and accredited by the Joint Committee on
Accreditation of Health Care Organizations.
The Ambulatory Surgical Center is an outpatient facility, therefore, your
insurance carrier will be billed a facility fee and any outpatient deductibles
and/or co-pay for your individual insurance plan will apply. If you are
uncertain of your policy deductibles, please contact your insurance carrier
for this information. You will be responsible for the deductible and co-pay.
These will be due at time of service.
For the comfort and safety of patients undergoing endoscopic procedures,
physicians and nurse anesthetists employed through Anesthesia
Advantage of Newtown, PA. provide conscious sedation during the
endoscopic procedure. Anesthesia Advantage will bill your insurance
carrier and deductibles and/or co-pays will apply.
Patients without insurance will be required to make financial arrangements
prior to performance of procedure.
Thank you.
Billing Dept. - Gastrointestinal Specialists, Inc. 610-664-9730 or 9731
Billing Dept. - Anesthesia Advantage 215-860-4110

GASTROINTESTINAL SPECIALISTS
Aria Torresdale Medical Office Bldg. Barix Clinic
3998 Red Lion Rd S.242 280 Middletown Blvd
Philadelphia, Pa 19114 Langhorne, Pa 19047
215-632-3500 215-702-7090


Patient Name: ____________________________________________
Patient Date of Birth: _______/_______/_______
Date of Procedure: _______/_______/_______
In order to maintain compliance with the Pennsylvania Human Relations
Act of 1955 and Title VI of the Federal Civil Rights Act of 1964, the
Ambulatory Surgical Center is asked to prepare documentation of the
following information regarding patient visits. Answers to the following
questions are entirely voluntary on the part of the patient.
Racial Background: _______________________________________
Religious Preferences: _____________________________________
Decline to Answer: ________________________________________

Patient Signature

Source: http://www.gispecialists.com/docs/Endoscopy%20instructions.pdf

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