Order Cancellation Form

To: customerserviceuk@electrocore.com

I/We* hereby give notice that I/we* cancel my/our* contract of sale of the following goods* / for the supply of the following:

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Ordered on* / received on*: ………………………………..

Names of Customer(s): ………………………………………

Address of Customer(s): ………………………………………

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Signature of Customer(s): …………………………………..

Date: …………………………………

*Delete as appropriate

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