Okla. Stat. tit. 43A § 11-110
EXAMINER'S CERTIFICATION
We, the undersigned, have made an examination of _______________, and do hereby certify that we made a careful personal examination of the actual condition of the person and on such examination we find that _____________________:
The facts and circumstances on which we base our opinions are stated in the following report of symptoms and history of case, which is hereby made a part hereof.
According to the advance directive for mental health treatment, (name of consumer)_________________________________________, wishes to receive mental health treatment in accordance with the preferences and instructions stated in the advance directive for mental health treatment.
We are duly licensed to practice in the State of Oklahoma, are not related to _______________by blood or marriage, and have no interest in her/his estate.
Witness our hands this ____________ day of _____________, 20__
___________________, M.D., D.O., Ph.D., Other
___________________, M.D., D.O., Ph.D., Other
Subscribed and sworn to before me this _______________________ day of ________________, 20__
Notary Public
REPORT OF SYMPTOMS AND HISTORY OF CASE BY EXAMINERS
Complete name ________________________________________________
Place of residence ___________________________________________
Sex _______________Color ________________
Age _______________
Date of Birth ________________________________________________
__________________________________________________________________
Our determination that the declarant (is) (is not) incapable of participating in mental health treatment decisions is based on the following:________________________________________________________
__________________________________________________________________
Other data ___________________________________________________
Dated at _____________, Oklahoma, this __________day of ___________________, 20__
_____________, M.D., D.O., Ph.D., Other
Address _____________, M.D., D.O., Ph.D., Other
_______________________________________Address
Okla. Stat. tit. 43A, § 11-110