Cancellation Form

To: Cochlear Europe Limited of 6 Dashwood Lang Road, Bourne Business Park, Addlestone, Surrey, KT15 2HJ.

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*: ………………………………..

Names of consumer(s): …………………………………….

Address of consumer(s):

…………………………………..……………………………………………………………….………………………………………………………………….

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

Date: …………………………………

*Delete as appropriate