If you wish to withdraw from the contract, you can complete this form and send it back to us, most easily by e-mail to info@lucerna.care. Using it is not obligatory.
To: Privatarztpraxis R. Janušas OREME, Hauptstrasse 2, CH-9053 Teufen AR, Switzerland, E-Mail: info@lucerna.care
I/We (*) hereby give notice that I/We (*) withdraw from my/our (*) contract for the provision of the following service (*): ______
Ordered on (*): ______
Name of consumer(s): ______
Address of consumer(s): ______
Signature of consumer(s) (only if this form is notified on paper): ______