"By signing the above, I am stating that I am board-certified in plastic surgery by the American Board of Plastic Surgeons or the Royal College of Physicians and Surgeons of Canada, that my medical license in the state where I am practicing is current and has not been revoked (nor has it been revoked in any other state), and that I am not currently being investigated or disciplined for medical malpractice, or being considered for discipline for medical malpractice, by the Board of Medical Examiners of any state or country, nor has any Medical Board or comparable supervisory board deemed it necessary to bring disciplinary action against me in the past 5 years of longer.

I further state there have been no malpractice judgments or settlements against me for a minimum of 5 years..."