California Code, Welfare and Institutions Code - 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:

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

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

Reasons for the recommendation

Date ․․․․․․․․․․․․․․․․.