Shenandoah Valley Gastroenterology logo

Harrisonburg 540-437-0087 | Waynesboro 540-946-1662

Complete these 4 forms in preparation for your first visit

We provide the forms in Google Docs format so that you can open and print from your browser on any device.

1. Patient Demographic Form
2. Medical History Form
3. Authorization Release Form (if you would like us to request your records)

Notice of Privacy Practices

Review our privacy policy (short and long form available)

4. Receipt of Notice of Privacy Practices

Bowel Preparation

How well you prepare for your procedure determines how well Dr. Pou can see what he needs to see. Bowel preparation is your responsibility. Please do not wait until the day prior to your procedure to read the instructions. Contact our office if you have any questions.

On or before the day of your appointment

Wear loose fitting, comfortable clothing — sweats, shirt or blouse with buttons down the front; no corsets, girdles, or panty hose; leave jewelry at home; remove any nail polish; do not bring any money.

Follow the directions about eating and drinking, and take your morning medications as directed.

Bring your insurance card(s).

Bring your driver's license or photo identification.

Bring a list of medicines you take and their dosages — inform us of any and all medications that you take.

Bring a list of any allergies that you have.

Bring a list of any previous problems with anesthesia, surgery, blood transfusions or medical problems.

A reminder that you may have lab work, EKG, and/or chest x-ray.

You may be at the endoscopy suite from 1½ to 3 hours, depending on your surgery or procedure.

Make arrangements for someone to drive you home after your procedure — although you will be monitored in a recovery area until all effects of the anesthesia have disappeared, having someone drive you home is a necessary safety precaution.


For your convenience, we provide the instructions in Google Docs format so that you can open and print from your browser.

If you are having an upper endoscopy, follow these instructions:

Preparation for Upper Endoscopy [opens in Google Docs]

If you are having a colonoscopy, follow these instructions:

Citrate of Magnesia Preparation [opens in Google Docs]

GOLYTELY/SPLIT Preparation for Colonoscopy

Low Residue Diet Options [opens in Google Docs]

Clear Liquid Diet [opens in Google Docs]









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