Healthcare Lingzhi Form

HEALTHCARE LINGZHI FORM

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History & Current Medications

Diabetes    Hypertension    Autoimmune disease    Bleeding disorder

I am currently taking anticoagulant or antiplatelet medication (e.g., warfarin, clopidogrel)   

I am currently taking immunosuppressant medication (e.g., steroids, biologics)

Pregnancy / Lactation:

Lingzhi Therapy — Description, Risks, and Expected Benefits

Lingzhi (Ganoderma lucidum, commonly referred to as Lingzhi) is a medicinal mushroom administered orally as a standardized extract, capsule, tincture, or powder as part of integrative healthcare. The anticipated clinical benefit may include support for general well-being, immune modulation, or symptom relief as discussed with your practitioner. Individual results are not guaranteed.

Known or potential risks and side effects include, but are not limited to: gastrointestinal upset, allergic reaction, headache, dizziness, changes in blood glucose, and possible interactions with anticoagulant, antiplatelet, antidiabetic, or immunosuppressive medications. Rarely, severe allergic reactions or hepatic effects have been reported. The long-term safety profile in pregnancy and lactation is not established.

Contraindications include known allergy to fungi, concurrent use of medications with significant interaction potential unless approved by prescribing clinician, and pregnancy where benefits do not clearly outweigh risks.

Informed Consent and Authorization

I, the undersigned, have read and understand the information provided above regarding Lingzhi therapy. My practitioner has explained the nature, purpose, potential benefits, risks, and alternatives, and I have had the opportunity to ask questions and receive satisfactory answers. I understand that alternative therapies and no treatment are options.

I authorize the practitioner listed below to recommend and administer Lingzhi therapy as part of my care. I understand I may withdraw consent at any time by notifying the clinic in writing or verbally, and that withdrawal will not affect my right to future care or services.

I understand that while reasonable measures are taken to minimize risk, no treatment is without possibility of adverse events. To the fullest extent permitted by law, I release and hold harmless the practitioner and clinic from liability for adverse reactions or outcomes except for willful misconduct or gross negligence.

HIPAA & Privacy Acknowledgment

I acknowledge receipt of the clinic's Notice of Privacy Practices and authorize the release of protected health information as necessary for treatment, payment, and healthcare operations related to Lingzhi therapy. I authorize communication of appointment reminders and treatment information by phone, text, or email to the contact information provided above.

I consent to the use of de-identified clinical information for quality assurance, internal research, or educational purposes. I understand that identifiable information will not be used without separate written authorization unless required by law.

Acknowledgements

I understand the risks and potential interactions of Lingzhi therapy and have disclosed my full medication and supplement list to the practitioner.

I will notify my practitioner immediately if I become pregnant, plan to become pregnant, or am breastfeeding.

I agree to report any unexpected or adverse effects to the clinic promptly.

Practitioner / Clinic Information

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