Surgeon Signature:_________________________________Date Signed:_______________
By signing the above, I am stating that I am board-certified in plastic
surgery by the American Board of Plastic Surgery, Inc. 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of Physicians and Surgeons of Canada, that my medical license in the state where I am practicing is current and has not been
revoked (nor has it been revoked in any other state), and that, to the best of my knowledge, I am not currently being investigated or disciplined for medical malpractice, or being considered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 for a minimum of 5 years.
Updated July 2018
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