Membership Cancellation

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Please complete form to cancel your membership with Abbott Health & Wellness

Full Name (s) Please include family members names. *

Phone Number *

Birthday *

YYYY

I would like to cancel my membership with Abbott Health & Wellness *

Yes

i understand that I can continue to be a patient if Abbott Health & Wellness without a membership. *

Yes

I understand that I am no longer able to use the URGENT after hours number. *

Yes

I understand that my prescriptions will no longer be refilled following the cancellation of my membership, unless I am seen by a provider at a future visit. *

Yes

I understand that if I cancel my membership, I cannot rejoin as a member. However, I can be seen on a pay per visit basis. *

Yes

I understand that if this cancellation form is not completed 5 business days before my auto-charge date, then I will be charged for another month. Cancellations are not automated and will only be processed during office hours. *

Yes

Required

Please state the reason you are cancelling your membership. *

DIGITAL SIGNATURE - PLEASE TYPE YOUR NAME BELOW. *

Date: *

YYYY

Thank you for trusting us with your health! We hope to see you in the future.

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