- Multicare-Centrum.nl, Pasteurstraat 10, 2811 DX Reeuwijk Netherlands, info@multicare-centrum.nl, phone number: + 31 182 391 210 

- I / we [*] hereby give notice that I / we [*] cancel my / our [*] contract of sale of the following goods [*] / for the supply of the following service [*], - Ordered on [*] / received on [*]

- Name of consumer(s)

- Address of consumer(s)

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

- Date

[*] Delete as appropriate

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