"OPTIONAL EXAMINER'S CERTIFICATION
We, the undersigned, have made an examination of ___________, and do hereby certify that we have 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 patient) _____________________, 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 this state of New Mexico, 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 ________ Ethnicity ___________________________
Age ________
Date of Birth ____________________________________
Our determination that the principal (is) (is not) in need for mental health treatment is based on the following:
________________________________________________________________________________
________________________________________________________________________________
Our determination that the principal does not have the capacity to participate in the principal's mental health treatment decisions is based on:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Other data __________________________________________________
Dated at ________________, New Mexico, this _______ day of _______________, 20____
___________________________________________ M.D., D.O., Ph.D.,
___________________________________________ Other Address
___________________________________________ M.D., D.O., Ph.D.,
___________________________________________ Other Address."
NMS § 24-7B-5