Gym Cancellation Certificate from medicalcert.co.uk

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Name* This field is required.as it should appear on the certificate

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Date of Birth* This field is required.

Date

3

Sex* This field is required.

Female

Male

Prefer not to say

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Email* This field is required.where the certificate will be delivered

5

Phone* This field is required.

6

Would you like to suspend or cancel your membership?* This field is required.

Suspension

Cancellation

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How long would you like to suspend your membership for?* This field is required.

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Main reason for the cancellation or suspension* This field is required.

9

What is the injury / illness / diagnosis you are suffering from?* This field is required.

10

What was the reason for your hospitalisation? / What surgery did you undergo?* This field is required.

11

In the past month, have you had thoughts about suicide?* This field is required.

YESNO

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Have you ever made a suicide attempt?* This field is required.

YESNO

13

Are you having thoughts of suicide right now?* This field is required.

YESNO

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Please access urgent help via one of the 24hr services below:

Samaritans – for everyone
Call 116 123
Email jo@samaritans.org

Papyrus – prevention of young suicide HOPELINE247
Call 0800 068 41 41
Text 07860 039967
Email pat@papyrus-uk.org

Childline – for children and young people under 19
Call 0800 1111 – the number will not show up on your phone bill

or you can call 111 and they will help you find the support and help you need.

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Start date of your symptoms* This field is required.

Date

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Condition status* This field is required.

Ongoing

Partially Recovered

Recovered

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Please describe all your symptoms and timeline in detail. Please provide as much information and detail as possible.* This field is required.More detail will help our doctors issue your letter quickly. Insufficient detail may delay your letter, as our doctors may have to contact you for further clarification before issuing a letter.

20 words minimum.

0/0

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Name of your Gym or Health Club* This field is required.

19

Are you pregnant or breastfeeding?* This field is required.

Yes

No

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Please provide details regarding your pregnancy* This field is required.

21

Have you sought medical care from your GP or local A&E for your medical issue before?* This field is required.

Yes, from my GP

Yes, I visited A&E

No, never consulted a doctor for this before

22

What treatment was administered in A&E or by your GP?* This field is required.

23

Please upload photos of your A&E discharge summary or clinical letters, if available

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

24

Please list any underlying health issues or past medical history:If none, leave empty

25

Please list any regular medication you take, whether prescribed or over-the-counter:If none, leave empty

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Medical Evidence

In order to issue your certificate, in the next pages you will be asked to provide:

A selfie for ID verification
A short video (30 sec - 1 min) of you describing your symptoms or photos of condition
A photo of your ID or Passport

Note: If you do not have your documents to hand, you can click the save icon below to save and return to this form later.

27

Please attach a short video of you describing your symptoms or condition (30 sec - 1 min)* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

28

Please attach a form of ID as proof of identification.* This field is required.Accepted forms of ID include: photo of your driver's license, passport, work badge, residence permit, or military ID card.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Terms* This field is required.

I agree that upon submitting my medical consultation, I acknowledge the Terms and Privacy Policy and consent to the following: I am NOT seriously unwell with any of the following symptoms: chest pain, shortness of breath, unrelenting severe headache, worsening severe abdominal pain, loss of vision, thoughts of suicide, confusion, ongoing bleeding, unable to swallow fluids or saliva, loss of limb sensation or control, facial numbness or weakness, slurred speech. I understand the questions in the questionnaire and answered them honestly. The requested letter is solely for the individual with the provided name and details. Medical Cert is not a replacement for a doctor's visit. I confirm I do not think I need to see a medical professional in person. Medical Cert is not my primary doctor or GP, and the doctor issuing my certificate may be unable to access my NHS or regular GP medical records. Medical Cert facilitates access to private medical letters and does not issue Med3 notes, which are obtainable through your NHS GP for UK government benefits. Medical Cert is unable to process refunds once a medical letter has been written and sent to you. If my symptoms persist or I have not fully recovered, I agree to consult with my regular doctor or GP for further medical advice. I consent to having this website store my submitted information so they can respond to my inquiry.

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Gym/Health Club Cancellation

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My Products* This field is required.

My Bag

1

Gym & Health Club CancellationDelivery before 9AM next day
£39.00Edit
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