Withrawal from the contract form

Firstname

Lastname

E-mail address

Order Number

In order to improve our service, we ask for the reason of the withdrawal from the contract.

Withdrawal from the contract. Please, complete with your order details.

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Attachments (PDF/JPG/JPEG/PNG/TXT/DOC/DOCX) — up to 5 files, total 10 MB

We would also like to inform you that the Controller of the personal data processed as part of this correspondence is Medicover Sp. z o.o., Al. Jerozolimskie 96, 00-807 Warsaw. The personal data will be processed for the purpose of handling complaints and based on the legitimate interest of the Controller. A detailed information clause on the processing of personal data is available at information clause. We kindly request you to read the clause and the Privacy Policy.