CASE NUMBER(S): _________________________________ ADDENDUM: CONTACT INFORMATION FOR THE ORDER APPOINTING DOCTOR(S) FOR PC § 1367/68 EXAMINATION [THIS PAGE FOR EXAMINER'S USE ONLY--This is not part of the Order] Defendant: Last Name First Name Middle DOB Address: (where out-of-custody Defendant can be contacted) Phone(s): (home, work, cell, parent or spouse, or a phone where a message may be left) I believe it is unlikely that the defendant will be able to keep an appointment to be examined in San Francisco? Yes No Reason for PC § 1367: I will call UCSF directly to provide this information. Ordering Judge: Mark R. Forcum Deputy Clerk: Jenny Rocha ATTORNEYS OF RECORD: DEFENSE ATTORNEY: Name: Phone: Email: DEPUTY DISTRICT ATTORNEY: Name: Melissa McKowan Dept: 8 Ext: (650) 261-5108 Phone: (desk) (650) 363-4774; (cell) (650) 888-5119 Email: mmckowan@smcgov.org INSTRUCTIONS for Person Submitting ORDER to Examiner(s): Please complete and email to UCSF Psychiatry and the Law Program at John.Chamberlain@ucsf.edu, along with the ORDER, the Police Report and the complaint CONTACT INFORMATION ADDENDUM FOR ORDER APPOINTING DOCTOR(S)) ** THIS PAGE FOR EXAMINER'S USE ONLY AND IS NOT PART OF THE ORDER ** CR-169 Addendum [Rev. 5/17] Mandatory Form American LegalNet, Inc. www.FormsWorkFlow.com