Withdrawal Form

Please fill out and submit this form if you wish to withdraw from the purchase contract to the seller:

Programme Health a.s.
Address: Drobného 27, 841 01 Bratislava
Company ID (IČO):

I hereby withdraw from the purchase contract for the goods:

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Order Number:

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Date of Receipt of Goods:

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Consumer's Name and Surname:

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Consumer's Address:

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Account for Payment Refund:

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IBAN:

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Consumer's Signature:

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Date:

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Place:

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