Contract Withdrawal Form Template

Contract Withdrawal Form Template (fill in this form and send it back only if you want to withdraw from the Contract)

Notice of Withdrawal from the Contract

PRAGA MEDICA HEALTHCARE s.r.o., with its registered office at Na Krutci 368/5, Prague 6, the Czech Republic, ID No. 24249726, registered in the Commercial Register kept by the Municipal Court in Prague, under File No. C 197135, (hereinafter referred to as the "Company")... I / We declare* that I /we hereby withdraw* from the Contract on mediation of health and other services (please specify the package of services below):

Date of ordering the services: Click here and enter the date. Date of the ordered procedure: Click here and enter the date. Your name and surname: Your address:

If you are sending the withdrawal in a written form, please attach your signature:

______

Date: Click here and enter the date.