<p> Contract Withdrawal Form Template (fill in this form and send it back only if you want to withdraw from the Contract)</p><p>Notice of Withdrawal from the Contract</p><p>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):</p><p>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: </p><p>If you are sending the withdrawal in a written form, please attach your signature: </p><p>______</p><p>Date: Click here and enter the date.</p>