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Main page » Model withdrawal form

Withdrawal

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

To

Wirth-Medizintechnik
Jürgen Wirth
Tulpenstrasse 39
95488 Eckersdorf
Germany

Fax: 0921-39337
E-Mail: info@wirth-medizintechnik.de

Withdrawal

Details to identify the contract

e.g. order number, product name or order date

Name of consumer(s)

Firstname

Lastname

Electronic means of communication for us to send you the acknowledgement of receipt of your withdrawal

Electronic means of communication (email address)

Privacy I have read the privacy notice.

* required

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