Terms & Conditions
Welcome to Independent Physiological Diagnostics Ltd! We provide home sleep and neurological diagnostic testing.
In these terms and conditions (Terms), when we say you or your, we mean both you, the person placing an order for services (Services) and if applicable, any entity you are representing (such as your employer). When we say we, us or our, we mean Independent Physiological Diagnostics Ltd, a company registered in England and Wales with company number 11950087. These Terms are entered into between us and you, each a Party and together the Parties. These Terms form our contract with you, and set out our obligations as a service provider and your obligations as a customer. You cannot use our Services unless you agree to these Terms. Some capitalised words in these Terms have defined meanings, and each time that word is used in these Terms it has the same meaning. You can find a list of the defined words and their meaning throughout these Terms or at the end of these Terms. For questions about these Terms, or to get in touch with us, contact us using the details below:​​
Our contact details:
Independent Physiological Diagnostics Ltd a company registered in England and Wales.
Our company registration number is 11950087
Address: 559a Kings Road, London, England SW6 2EB, United Kingdom
Phone: 0207 381 8698
Email: enquiries@ipdiagnostics.co.uk
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1. These Terms
1.1 What these Terms Cover: These Terms contain the terms and conditions on which we supply the Services to you.
1.2 Please read these Terms carefully before you accept these Terms. These Terms tell you who we are, how we will provide the Services to you, how you and we may change or end these Terms, what to do if there is a problem with the Services and other important information. If you think that there is a mistake in these Terms or require any changes to these Terms, please contact us to discuss (using our contact details above).
1.3 How to tell us about problems: If you have any questions or complaints about the Services, please contact us to discuss (using our contact details above).
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2. Acceptance and Term
2.1 You accept these Terms by checking the box and providing us with your signature.
2.2 These Terms apply from when you have accepted these Terms in accordance with clause 2.1 , until we have completed the supplyof the Services, as reasonably determined by us.
2.3 If you make a booking for the Services, and you expressly request that we start providing the Services to you within your 14-day cancellation period, you acknowledge that you will lose your right to cancel within the first 14 days under the consumer laws.
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3. Our supply of the Services
3.1 In consideration of your payment of the Price, we will provide the Services in accordance with these Terms and all applicable Laws, whether ourselves or through our Personnel.
3.2 We warrant to you that the Services will be provided using reasonable care and skill.
3.3 We will not be responsible for any Services unless expressly set out in the Patient Booking Confirmation.
3.4 As part of the Services, we may provide the results in the form of a report (Report). If you have been referred to us by a medical practitioner then the Report will be delivered to the medical practitioner, and if you have not been referred to us by a medical practitioner then the Report will be delivered to you. You should seek advice on your Report from a registered and appropriately qualified healthcare practitioner. You acknowledge and agree that we only provide the Report as part of the Services, and you are solely responsible for seeking assistance in interpreting the Report and assessing the suitability of any recommendations in the Report with a healthcare practitioner.
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4. Professional Regulation
We are registered with the following regulatory bodies, and are subject to their respective codes of conduct, a copy of which is available on their respective websites via the links provided:
(a) Care Quality Commission - https://www.cqc.org.uk/about-us/fundamental-standards
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5. Equipment Hire
5.1 We may agree to provide you with equipment, which may include:
(a) 14 day actigraphy – Actiwatch Phillips;
(b) Sleep Positional Trainer;
(c) Lowestein Auto CPAP machine
(d) Respiratory polygraphy kit – Somno Touch;
(e) Polywatch respiratory kit; and
(f) Alice Night One respiratory kit, together, these form the Equipment.
5.2 The Equipment and whether it will be provided will be confirmed in the Patient Booking Confirmation, or as otherwise agreed between the Parties.
5.3 This clause 5 applies to the extent we have agreed to provide Equipment to you, for a defined period of time (Hire Period), as set out in the Patient Booking Confirmation.
5.4 If the Parties agree that:
(a) you are to collect the Equipment from us, you agree to collect the Equipment from the collection location and by the
collection time agreed between the Parties; or
(b) we are to deliver the Equipment to you, we agree to use our reasonable endeavours to deliver the Equipment to the
Premises in a reasonable period of time.
5.5 You agree to return the Equipment to us or make the Equipment available for collection by us (as agreed between the Parties in writing) in the Original Condition, at the return location and by the return time we notify you.
5.6 You agree to contact us immediately if there are any technical or mechanical issues, or any other defects, with the Equipment.
5.7 You agree to:
(a) protect and keep the Equipment in the Original Condition; and
(b) prevent the Equipment from being subject to any loss, theft, damage, vandalism or destruction and notify us immediately if the Equipment is stolen, lost, destroyed, or otherwise damaged.
5.8 Risk in the Equipment will pass to you when the Equipment comes into your physical possession.
5.9 Title in the Equipment will at all times remain with us, and you take the Equipment as a bare bailee only.
5.10 Without limiting our rights or entitlements under these Terms or at law, if you fail to return the Equipment before the expiry of the Hire Period, you must pay us on demand liquidated damages of £50 per 24 hour period or part thereof until (and
including) the time that the Equipment is returned to us.
5.7 You acknowledge and agree that the rate of liquidated damages represents a genuine pre-estimate of our likely losses arising as a result of your failure to return the Equipment to us in accordance with these Terms. You acknowledge and agree that any liquidated damages payable to us under this clause will not constitute our sole and exclusive remedy in relation to your failure to return the Equipment to us before the expiry of the Hire Period.
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6. Your Right to Make Changes to the Services and These Terms
If you wish to make a change to the Services you have ordered please contact us. We will let you know if the change is possible. If it is possible, we will let you know about any changes to the Price of the Services, the timing of supply of the Services or anything else which would be necessary as a result of your requested change, and ask you to confirm whether you wish to go ahead with the change.
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7. Cancellations and Rescheduling
7.1 This clause 7 applies to the extent that we have agreed to attend the Premises to provide the Services, as set out in your Patient Booking Confirmation. The Parties will work together to agree a date, location, and time for us to supply the Services at the Premises (Appointment).
7.2 In the unlikely event that we need to cancel an Appointment due to no fault on your part, such as where our team is unwell, or due to adverse weather conditions, we will aim to provide you with as much notice as possible.
7.3 If, for any reason, you need to reschedule an Appointment with us, we would appreciate you giving us as much notice as you can, and in any event, at least 24 hours’ notice prior to the Appointment by calling or emailing us using the contact details at the beginning of these Terms. Where you fail to provide us with at least 24 hours’ notice to reschedule your Appointment, you agree to pay us a fee that constitutes the Price (Cancellation Fee).
7.4 If we attend the Premises and you are not available, or if we attend the Premises and are unable to provide the Services due to no fault on our part, including but not limited to where you fail to comply with instructions or where you are unable to tolerate the Services, you agree to pay us the Cancellation Fee.
7.5 You acknowledge and agree that the Cancellation Fee is a genuine pre-estimate of our loss arising as a result of your failure to give us notice of your unavailability, or comply with our instructions.
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8. Your Right to Make Changes to the Services and These Terms
8.1 You have 14 days after the date you accept these Terms to change your mind and cancel the Services. We agree not to commence the provision of the relevant Services during this cancellation period, unless you make an express request for us to do so. You acknowledge and agree that after you have accepted these Terms, if you instruct us to provide the relevant Services within this cancellation period, this will be taken to be an express request by you, and you will lose your right to cancel if the relevant Services are fully performed by us. If you exercise your right to cancel under this clause 8 . you will be liable to pay to us an amount for the relevant Services supplied up to when you inform us that you intend to cancel, which will be proportionate to the full Price for the relevant Services for the Term.
8.2 When you don't have the right to change your mind: You do not have a right to change your mind in respect of Services, once these have been completed if you expressly requested us to provide them during the cooling off period, even if the cooling off period is still running.
8.3 Tell us you want to cancel these Terms: To exercise your right to cancel these Terms under this clause 8 , please let us know by contacting us by email using the email address at the start of these Terms.
8.4 When your refund will be made: We will make any refunds due to you as soon as possible, and within 14 days of your informing us that you have changed your mind.
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9. Payment
9.1 You must pay us the purchase price of each Service you order, plus any other amount payable to us under these Terms as set out on the Patient Booking Confirmation details (the Price) and in accordance with this clause. All amounts are stated in pounds sterling, being the currency of the United Kingdom from time to time, and are inclusive of value added tax (or any equivalent tax in the UK), where applicable.
9.2 Where you nominate an insurer or other third party to make payment of the Price on your behalf (Third Party Payer), you acknowledge and agree that the Third Party Payer is acting as an agent on your behalf, and any part-payment by the Third Party Payer does not relieve you of your obligations to pay the Price or other obligations under these Terms. Where the Third Party Payer fails to pay the Price in full, you acknowledge and agree that you will remain responsible for paying the balance of the Price.
9.3 If any payment has not been made in accordance with these Terms, we may (at our absolute discretion) charge interest at a rate equal to 4% above the Bank of England's base rate, from time to time, but at 4% a year for any period when that base rate is below 0%, per annum, calculated and compounding monthly, on any such amounts unpaid after the due date for payment in accordance with these Terms.
9.4 Where you are self-funding the Services: You will not be entitled to any part of the Services until the Price has been paid in full.
9.5 Where you are paying through a Third Party Payer: You may nominate a Third Party Payer to receive our invoice on your behalf. We will issue an invoice to your Third Party Payer on completion of the Services (as reasonably determined by us). Your Third Party Payer must pay the Price, and any other amount due to us in accordance with these Terms, set out in the invoice, using the payment method set out in the invoice, within 30 days of the date of the invoice, or as otherwise agreed between the Parties. Where your Third Party Payer only makes a part-payment of the Price, we will invoice you for the remaining balance. You must pay the amount set out in our invoice within 14 days of the date of the invoice.
9.6 You must not pay, or attempt to pay, the Price by fraudulent or unlawful means. If you make a payment by debit card or credit card, you warrant that you are authorised to use the debit card or credit card to make the payment.
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10. Premises
10.1 You agree to provide us (and our Personnel) with access to the Premises (and the facilities at the Premises) and any other premises as is reasonably necessary for us to provide the Services, free from harm or risk to health or safety:
(a) at the times and on the dates reasonably requested by us or as agreed between the Parties; and/or
(b) to enable us to comply with our obligations under these Terms or at Law.
10.2 You agree to pay our additional costs reasonably incurred as a result of you failing to comply with this clause 10.
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11. Warranties and Representations
11.1 Each Party represents, warrants and agrees that:
(a) it has full legal capacity, right, authority and power to enter into these Terms, to perform its obligations under these Terms, and to carry on its business;
(b) that these Terms constitute a legal, valid and binding agreement, enforceable in accordance with its terms;
(c) if applicable, it holds a valid company number which has been advised to the other Party; and
(d) if applicable, it is registered for VAT purposes.
11.2 You represent, warrant and agree:
(a) to comply with these Terms and all applicable Laws;
(b) that all information and documentation that you provide to us in connection with these Terms is true, correct and complete;
(c) to comply with our reasonable requests or requirements;
(d) that you (and to the extent applicable, your Personnel) will provide us with all documentation, information, instructions,
cooperation and access reasonably necessary to enable us to provide the Services;
(e) to provide us with the details of any Third Party Payer prior to our issuing of an invoice to you;
(f) that you will keep the Equipment under your custody and control at all times, and you will not sublease, rent, sell or otherwise transfer the Equipment to any other person;
(g) that you have not relied on any representations or warranties made by us in relation to the Services (including as to
whether the Services are or will be fit or suitable for any particular purposes), unless expressly stipulated in these Terms; and
(h) that the Services are provided to you solely for your benefit and you will not (or you will not attempt to) disclose, or provide access to, the Services to third parties without our prior written consent.
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12. Intellectual Property
12.1 As between the Parties we own all Intellectual Property Rights in Our Materials.
12.2 As between the Parties, ownership of all Intellectual Property Rights in any New Materials or Improvements will at all times vest, or remain vested, in us upon creation. To the extent that ownership of such Intellectual Property Rights in any New Materials and/or Improvements do not automatically vest in us, you agree to do all things necessary or desirable to assure our title in such rights.
12.3 We grant you a non-exclusive, revocable, worldwide, non-sublicensable and non-transferable right and licence, to use Our Materials that we provide to you, the New Materials and Improvements, solely for the purposes for which they were developed and for your use and enjoyment of the Services, as contemplated by these Terms.
12.4 Nothing in these Terms constitutes a transfer or assignment of any Intellectual Property Rights.
12.5 This clause 12 will survive termination or expiry of these Terms.
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13. Confidential Information
13.1 The parties acknowledge that the collection of personal data (including health data) is a necessary part of providing the Services.
13.2 We agree to comply with the Data Protection Act 2018, and we will handle your personal data in accordance with our privacy policy, available at https://www.ipdiagnostics.co.uk/privacy
13.3 Subject to the exclusions set out in clause 13.4 , we agree to keep all confidential information (including any personal data and health data) that you share with us in the course of providing the Services, private and confidential.
13.4 We may disclose the confidential information (including any personal data) you share with us in the course of providing the Services:
(a) to a medical or other healthcare practitioner, to the extent you were referred to our Services by them, including to provide
them with the results of the Services;
(b) to a third party in connection with our provision of the Services, including another medical practitioner, insurer, family
member, or third party funder; or
(c) to a third party where we form the reasonable belief that there is an immediate and specific risk of harm (to life, health or
safety) to you or another identifiable person or persons that can be avoided only by disclosing the confidential information.
13.5 This clause 13 will survive the termination of these Terms.
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14. Problems with the Services
14.1 See the box below for a summary of your key legal rights in relation to the product. Nothing in these Terms will affect your legal rights.
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Summary of your key legal rights
This is a summary of your key legal rights. These are subject to certain exceptions. For detailed information please visit the Citizens Advice website www.adviceguide.org.uk or call 03454 04 05 06.
The Consumer Rights Act 2015 says: You can ask us to repeat or fix a service if it's not carried out with reasonable care and skill, or get some money back if we can fix it.
If you haven't agreed a price beforehand, what you're asked to pay must be reasonable.
If you haven't agreed a time beforehand, it must be carried out within a reasonable time.
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15. Limitations on and exclusions to our liability
15.1 Neither Party may benefit from the limitations and exclusions set out in this clause 15 in respect of any liability arising from its deliberate default.
15.2 The restrictions on liability in this clause 15 apply to every liability arising under or in connection with these Terms including liability in statute, contract, equity, tort (including negligence), misrepresentation, restitution, indemnity or otherwise, howsoever arising, whether direct or indirect and/or whether present, unascertained, future or contingent and whether involving a third party or a Party to these Terms or otherwise.
15.3 Nothing in these Terms limits any Liability which cannot legally be limited, including liability for:
(a) death or personal injury caused by negligence;
(b) fraud or fraudulent misrepresentation;
(c) breach of the terms implied by section 2 of the Supply of Goods and Services Act 1982 (title and quiet possession); and
(d) defective products under the Consumer Protection Act 1987.
15.4 Subject to clauses 15.1 (no limitation in respect of deliberate default), and 15.2 (liability which cannot legally be limited), but despite anything else to the contrary, to the maximum extent permitted by law:
(a) we only supply the Services for domestic and private use. If you use the Services for any commercial, business or re-sale
purpose we will have no liability to you for liability involving any loss of profit, loss of business, business interruption, or loss
of business opportunity;
(b) a Party’s liability for any liability under these Terms will be reduced proportionately to the extent the relevant liability was
caused or contributed to by the acts or omissions of the other Party (or any of its Personnel), including any failure by that
other Party to mitigate its loss; and
(c) our aggregate liability for any and all Liability arising from or in connection with these Terms will be limited to 100% of the Price paid.
15.5 We have given commitments as to the compliance of the Services with these Terms and applicable Laws in clause 3 . In view of these commitments, the terms implied by sections 3, 4 and 5 of the Supply of Goods and Services Act 1982 are, to the maximum extent permitted by law, excluded from these Terms.
15.6 This clause 15 will survive the termination or expiry of these Terms.
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16. Termination
16.1 Nothing in this clause 16 limits any right you have to change your mind under clause 16 . If you want to cancel or terminate these Terms, you should use the Model Cancellation Form at Attachment 1.
16.2 These Terms will terminate immediately upon written notice by a Party (Non-Defaulting Party) if:
(a) the other Party (Defaulting Party) breaches a material provision of these Terms and that breach has not been remedied
within 5 Business Days of the Defaulting Party being notified of the breach by the Non-Defaulting Party; or
(b) the Defaulting Party is unable to pay its debts as they fall due.
16.3 Upon expiry or termination of these Terms:
(a) we will immediately cease providing the Services;
(b) to the maximum extent permitted by law, you agree that any payments made by you to us are not refundable to you;and
(c) you are to pay for all Services provided prior to termination, including Services which have been provided and have not yet been invoiced to you, and all other amounts due and payable under these Terms;
(d) you must promptly return any Equipment to us or you agree to grant us such rights of access to any premises where the
Equipment is located to allow us (or our Personnel) to recover or repossess any Equipment belonging to us; and
(e) you agree to promptly return (where possible), or delete or destroy (where not possible to return), any information,
documentation or material owned by us that is in your possession or control, subject to any rights you may have to any
Intellectual Property in accordance with clause 12.
16.4 We will retain your documents (including copies) as required by law or regulatory requirements. Your express or implied agreement to these Terms constitutes your authority for us to retain or destroy documents in accordance with the statutory periods, or on expiry or termination of these Terms.
16.5 Termination of these Terms will not affect any rights or liabilities that a Party has accrued under it.
16.6 This clause 16 will survive the termination or expiry of these Terms.
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17. General
17.1 Amendment: These Terms may only be amended by written instrument executed by the Parties.
17.2 Assignment: Subject to clause 17.3 , a Party must not assign or deal with the whole or any part of its rights or obligations under these Terms without the prior written consent of the other Party (such consent is not to be unreasonably withheld).
17.3 Assignment of Debt: You agree that we may assign or transfer any debt owed by you to us, arising under or in connection with these Terms, to a debt collector, debt collection agency, or other third party.
17.4 Contracts (Rights of Third Parties) Act 1999: Not withstanding any other provision of these Terms, nothing in these Terms confers or is intended to confer any right to enforce any of its terms on any person who is not a party to it.
17.5 Disputes: Alternative dispute resolution is a process where an independent body considers the facts of a dispute and seeks to resolve it, without you having to go to court. If you are not happy with how we have handled any complaint, you may want to contact the alternative dispute resolution provider we use. You can submit a complaint to The Centre for Effective Dispute Resolution via their website at https://www.cedr.com/. The Centre for Effective Dispute Resolution will not charge you for making a complaint and if you are not satisfied with the outcome you can still bring legal proceedings.
17.6 Entire agreement: Subject to your consumer law rights, these Terms contain the entire understanding between the Parties and the Parties agree that no representation or statement has been made to, or relied upon by, either of the Parties, except as expressly stipulated in these Terms, and these Terms supersede and extinguish all previous discussions, communications, negotiations, understandings, representations, warranties, commitments and agreements, whether written or oral, in respect of its subject matter. Each Party agrees that it will have no remedies in respect of any statement, representation, assurance or warranty (whether made innocently or negligently) that is not set out in these Terms.
17.7 Force Majeure: Neither Party will be liable for any delay or failure to perform their respective obligations under these Terms if such delay or failure is caused or contributed to by a Force Majeure Event, provided that the Party seeking to rely on the benefit of this clause:
(a) as soon as reasonably practical, notifies the other Party in writing of the details of the Force Majeure Event, and the extent to which it is unable to perform its obligations; and
(b) uses reasonable endeavours to minimise the duration and adverse consequences of the Force Majeure Event.
17.8 Governing law: These Terms are governed by the laws of England and Wales. Each Party irrevocably and unconditionally submits to the exclusive jurisdiction of the courts operating in England and Wales and any courts entitled to hear appeals from those courts and waives any right to object to proceedings being brought in those courts.
17.9 Notices: Any notice given under these Terms must be in writing addressed to the relevant address last notified by the recipient to the Parties. Any notice may be sent by standard post or email, and will be deemed to have been served on the expiry of 48 hours in the case of post, or at the time of transmission in the case of transmission by email.
17.10 Severance: If a provision of these Terms is held to be void, invalid, illegal or unenforceable, that provision is to be read down as narrowly as necessary to allow it to be valid or enforceable, failing which, that provision (or that part of that provision) will be severed from these Terms without affecting the validity or enforceability of the remainder of that provision or the other provisions in these Terms. If any provision or part-provision of these Terms is deemed deleted under this clause 17.3, the Parties will negotiate in good faith to agree a replacement provision that, to the greatest extent possible, achieves the intended commercial result of the original provision.
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18. Definitions
Business Day means a day on which banks are open for general banking business in England and Wales, excluding Saturdays, Sundays and bank holidays.
Dispute has the meaning given in clause 17.5.
Force Majeure Event means any event or circumstance which is beyond a Party’s reasonable control including but not limited to, acts of God including fire, hurricane, typhoon, earthquake, landslide, tsunami, mudslide or other catastrophic natural disaster, civil riot, civil rebellion, revolution, terrorism, insurrection, militarily usurped power, act of sabotage, act of a public enemy, war (whether declared or not) or other like hostilities, ionising radiation, contamination by radioactivity, nuclear, chemical or biological contamination, any widespread illness, quarantine or government sanctioned ordinance or shutdown, pandemic (including COVID-19 and any variations or mutations to this disease or illness) or epidemic.
Improvements means any development, modification, adaptation or improvement of Our Materials or any New Materials made by or on behalf of either Party (or any of their respective Personnel), or in respect of which Intellectual Property Rights are acquired by, either Party during the Term.
Intellectual Property means any copyright, registered or unregistered designs, patents or trade marks, business names, get up, goodwill, domain names, know-how, inventions, processes, trade secrets or Confidential Information, circuit layouts, software, computer programs, databases or source codes, including any application, or right to apply, for registration of, and any improvements, enhancements or modifications of, the foregoing.
Intellectual Property Rights means for the duration of the rights in any part of the world, any industrial or intellectual property
rights, whether registrable or not, and including all applications and rights to apply for and be granted, renewals or extensions of, and rights to claim priority from, such rights and all similar or equivalent rights or forms of protection which subsist or will subsist now or in the future, including in respect of Intellectual Property.
Laws means all applicable laws, regulations, codes, guidelines, policies, protocols, consents, approvals, permits and licences, and any requirements or directions given by any government or similar authority with the power to bind or impose obligations on the relevant Party in connection with these Terms or the supply of the Services.
Moral Rights means any moral rights, including those conferred by Chapter IV of the Copyright, Designs and Patents Act 1988.
New Materials means all Intellectual Property developed, adapted, modified or created by or on behalf of us or you or any of your or our respective Personnel in connection with these Terms or the supply of the Services, whether before or after the date of these Terms, but excludes Our Materials and Your Materials.
Original Condition means the condition the Equipment was delivered to you, including being clean, free from major defect or damage and in accordance with these Terms.
Our Materials means all work, models, processes, technologies, strategies, materials, information, documentation and services that we may provide to you under these Terms, and which may contain material which is owned by or licensed to us, and is protected by United Kingdom and international laws.
Patient Booking Confirmation means the communication sent by us to you, whether by phone, text message or email, confirming the date, time and details of your Appointment and the Services and/or Equipment (if applicable) to be provided by us, including a schedule of rates with the Price for our Services.
Personnel means, in respect of a Party, any of its employees, consultants, suppliers, subcontractors or agents, but in respect of you, does not include us.
Premises means the location at which we have agreed to deliver the Services, as set out on the Patient Booking Confirmation at the time of placing an order for the Services and/or Equipment.
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19. Interpretation
In these Terms, unless the context otherwise requires:
(a) A reference to these Terms or any other document includes the document, all schedules and all annexures as novated,
amended, supplemented, varied or replaced from time to time;
(b) A reference to any legislation or law includes subordinate legislation or law and all amendments, consolidations,
replacements or re-enactments from time to time;
(c) A reference to a natural person includes a body corporate, partnership, joint venture, association, government or statutory
body or authority or other legal entity and vice versa;
(d) No clause will be interpreted to the disadvantage of a Party merely because that Party drafted the clause or would
otherwise benefit from it;
(e) A reference to a party (including a Party) to a document includes that party’s executors, administrators, successors,
permitted assigns and persons substituted by novation from time to time;
(f) A reference to a covenant, obligation or agreement of two or more persons binds or benefits them jointly and severally;
(g) Any obligation on a Party not to do something includes an obligation not to allow that thing to be done;
(h) A reference to time is to local time in London; and
(i) A reference to £ or pounds refers to the currency of the United Kingdom from time to time.
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Model Cancellation Form
(Complete and return this form only if you wish to withdraw from the contract)
To [TRADER'S NAME, ADDRESS, TELEPHONE NUMBER AND, WHERE AVAILABLE, FAX NUMBER AND E-MAIL ADDRESS TO BE INSERTED BY
THE TRADER]:
I/We [*] hereby give notice that I/We [*] cancel my/our [*] contract of sale of the following goods [*]/for the supply of the following service [*]:
Ordered on [*]/received on [*]:
Name of consumer(s):
Address of consumer(s):
Signature of consumer(s) (only if this form is notified on paper):
Date:
[*] Delete as appropriate
© Crown copyright 2013.