EN | BA | Right of Withdrawal

MODEL WITHDRAWAL FORM

(Only complete and submit this form if you wish to cancel AND return (part of)
your Bariatric Advantage^® order within 14 days of receipt)

I hereby inform Bariatric Advantage that I revoke my agreement regarding the sale of the following product(s): *

Ordered on * +

Received on * +

Reason for Cancelation

Title *

Name *

Surname *

Street *

Nr *

Postal code *

City *

E-mail Address *

Telephone number

Date * +