Withdrawal Form

(Complete and return this form only if you wish to withdraw from the contract)

To:
Medi Malta
[Insert your address]
Email: [Insert your email address]

I/We hereby give notice that I/We withdraw from my/our* contract of sale of the following goods:**

• Ordered on: [insert date]

• Received on: [insert date]

• Order number: [insert order number]

• Name of consumer(s): [insert name(s)]

• Address of consumer(s): [insert address]

• Telephone/ mobile number of consumer(s): [insert number]

• Email of consumer(s): [insert email address]

• Signature of consumer(s) (only if this form is notified on paper):

  
  [insert signature]

• Date: [insert date]

*Delete as appropriate.