For the attention of 55 MEDISPA, SARL – 158 Avenue du Maine, 75014 Paris, France

I/we () hereby notify you () of my/our () withdrawal from the contract for the sale of the goods ()/for the provision of services (*) below:

Ordered on (*)/received on (*):

Name of consumer(s):

Address of consumer(s):

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

Date:

(*) Delete as appropriate.

Please send your letter by registered mail with acknowledgment of receipt to:

55 MEDISPA SARL

158 Avenue du Maine

75014 Paris

France

//@todo