Cal. WIC § 6253

Wherever provision is made in this code for court-appointed medical examiners to make and sign a certificate showing the facts of an examination in the case of a person alleged to be subject to judicial commitment, the certificate shall be in substantially the following form:
In the Superior Court of the State of California
for the County of ________

In the Superior Court of the State of California
for the County of ________

The People

For the Best Interest and Protection of

, ⎫
⎪
⎪
⎪ Certificate
of Medical
Examiners
as a and ⎬
⎪
Concerning , ⎪
and , ⎪
Respondents ⎪
⎭

We, Dr. ________ and Dr. ________, medical examiners in the County of ________, duly appointed and certified as such, do hereby certify under our hands that we have examined ________, alleged to be a ________, and have attended before a judge of said court at the hearing on the petition concerning said person, and have heard the testimony of all witnesses, and, as a result of the examination, have testified under oath before the court to the following facts concerning the alleged ____________:
Name

Address

Age Sex

Occupation Marital status

(Single, married, widowed, divorced)

Religious belief

Pertinent case history

General physical condition

Present mental status

Laboratory reports (if any)

Tentative diagnosis of mental health

Recommendation for disposition or supervision, treatment and care

Reason for the recommendation
Date ________________
Medical Examiner

Medical Examiner