Healthcare Cordyceps Form

Healthcare Cordyceps Form

This Healthcare Cordyceps Form documents patient health information, clinical screening, informed consent, and authorization for administration of cordyceps-containing preparations as part of an integrative therapeutic program. The patient named below consents to evaluation and treatment, acknowledges known risks and benefits, and authorizes appropriate use and limited release of protected health information for treatment, payment, and healthcare operations.

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Screening Questions (check all that apply)

Currently pregnant
Currently breastfeeding
Immunocompromised or on immunosuppressive therapy
Diagnosed autoimmune disorder
Taking anticoagulant or antiplatelet medication
History of organ transplant
Known allergy to fungi or mushroom-based products

Cordyceps Treatment Plan

Proposed Preparation: Capsule Tincture Infusion / Tea Topical

Dosage / Strength:    Frequency:

Planned Start Date:

Risks, Benefits, and Alternatives

Benefits: Cordyceps preparations are used in integrative practice with the intent to support energy, respiratory function, and general wellness. Clinical benefit is variable and not guaranteed. The patient understands that outcomes vary by individual.

Risks and Potential Adverse Effects: Known and potential risks include but are not limited to allergic reaction, gastrointestinal upset, headache, interactions with anticoagulant and immunomodulatory medications, alterations in blood sugar, and unforeseen idiosyncratic responses. Patients who are pregnant, breastfeeding, immunocompromised, or on anticoagulation or other prescription therapies may be at increased risk and should notify their prescribing clinician prior to use.

Alternatives: Alternatives include foregoing cordyceps therapy, using alternative botanical or pharmaceutical options as advised by your clinician, or pursuing non-pharmacologic supportive measures. The patient affirms they have discussed alternatives and had the opportunity to ask questions.

Authorization and Privacy Acknowledgment

I authorize the clinical staff to administer cordyceps-containing preparations as described in this form and to provide such medical care as deemed necessary in the event of a treatment-related adverse reaction, including emergency treatment. I authorize release of my protected health information to other treating providers and to my insurance carrier for purposes of treatment, payment, and healthcare operations.

I acknowledge receipt of the practice’s privacy notice and understand my rights with respect to my medical information. I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance upon it. This authorization will expire on the following date unless earlier revoked:

Emergency Consent: In the event I am unable to provide consent at the time of an adverse reaction, I authorize clinically appropriate emergency interventions including first aid, administration of medications, and transfer to an emergency facility if necessary.

Patient Certification

By signing below I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand the nature of the proposed cordyceps therapy, the attendant risks and potential benefits, and that no guarantees have been made regarding outcome. I voluntarily consent to the therapy described and understand I may withdraw consent at any time by notifying my clinician in writing.

Sign Now