Health & Saf. Code, § 118703

(a) The department shall develop a standard electronic form that may be signed by a health care provider, as specified in subdivision (b) of Section 118702, to serve as reasonable evidence of the existence of an eligible medical condition or use of an ostomy device. The department shall post the form, in a printable format, on the department’s internet website.

(b) The form shall include all of the following components:

(1) Space for the requesting individual’s name.

(2) Space for the requesting individual’s address.

(3) Space for the requesting individual’s date of birth.

(4) Space for the health care provider’s name, signature, and statement confirming the eligible medical condition or use of an ostomy device.

(5) Both of the following statements:

(A) “MEDICAL ALERT: RESTROOM ACCESS REQUIRED.”

(B) “The holder of this form uses an ostomy device or suffers from Crohn’s disease, ulcerative colitis, other inflammatory bowel disease, irritable bowel syndrome, or another medical condition that requires immediate access to a toilet facility.”

(6) A reference to this article and to any regulations adopted to implement this article.