DATE:____/____/____

Arrive at Hospital Admitting:_______________ (main entrance of hospital)

Time procedure begins:_______________

FOLLOW ONLY THE INSTRUCTIONS MARKED:

You may have NOTHING to eat or drink after midnight the night before your surgery.

Fill prescriptions and follow the instruction sheet given to you.

Give yourself two Fleet enemas two hours before leaving your home.

If you have any questions, please feel free to contact our office.