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Withdrawal form

Model Withdrawal Form

(This form must be completed and returned only if you wish to withdraw from the agreement)

Addressee: _________________________________________________________________

E-mail: _________________________________

I hereby inform you of my withdrawal from the agreement for the provision of the service provided on the website queryhealth.org

Date of conclusion of the contract ______________________________________________________________

First and last name of the consumer (s) ______________________________________________________

_______________________________________________________________________________

Login of the consumer (s) on the service queryhealth. org______________________________________

Signature of the consumer (s) ____________________________________________________________

Date