Application Form | Doctor's Note for Gym Membership Cancellation

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Full Name

First

Last

Sex

Mobile Number

Email Address

Your certificate will be sent to this email address

Date of Birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Name of Gym/Health Club:

Address of Gym/Health Club:

Date you joined:

When did your illness or injury begin?

Please describe your condition, injury, or medical issue and explain how it affects your ability to use the gym.

Have you consulted a healthcare professional about this issue?

Is there anything else you'd like to add to your application? (Optional)

Please leave this blank if you have nothing further to add

Would you like to upload any relevant documents for your application? (Optional)

Click or drag files to this area to upload. You can upload up to 100 files.

Please leave this blank if you have nothing further to add

Please upload an IMAGE of a form of photographic ID (e.g. passport, driving license) to confirm your identity:

Click or drag files to this area to upload. You can upload up to 100 files.

By submitting your application, you confirm that you understand our Terms and Privacy Policy, and you consent to the following:

You confirm that you have understood all the questions in the form and have provided truthful and accurate responses.
The letter requested is issued exclusively for the individual whose details have been provided in the application and cannot be transferred to any other person.
You acknowledge that Wilmer Health does not replace your primary care physician or GP. Our healthcare professionals do not have access to your medical records.
You acknowledge that Wilmer Health provides private medical letters and does not issue MED3 (fit note) certificates, which are available from your NHS GP for government benefits purposes.
Wilmer Health does not provide diagnostic, consultation, or treatment services. We do not accept liability for any adverse events affecting you or any third party, at any time.
You agree that Wilmer Health and its doctors are not liable for any negative outcomes affecting you or any other party, now or in the future.
Once a doctor has reviewed your request and the medical letter has been issued, you accept that no refunds will be provided.
You understand that if a third party rejects or does not accept the medical letter provided by Wilmer Health, neither Wilmer Health nor its doctors are responsible for any associated costs or consequences.
You agree to consult with your regular doctor, GP, or nearest Emergency Department for further medical advice regarding the medical issue you have described today.

Agreement to Terms and Conditions

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Doctor's Note for Gym Membership Cancellation

Price: £49.00