WELLBEE PLATFORM TERMS OF SERVICE
Hello!
In the following document, you will find all the essential information regarding the services we can provide to you as a User ("you," "your") through our Wellbee Platform (wellbee.pl). Here, you will also find details about how the Platform operates, hardware requirements, the scope of services, as well as your rights and obligations related to using our services.
These Terms may seem lengthy—unfortunately, we can’t help that—firstly, because we want you to have complete knowledge about our services and the Platform, and secondly, because the law requires us to provide you with comprehensive information.
Before you start using the Wellbee Platform, and especially before making any purchase through it, you must familiarize yourself with the information provided in these Terms and accept their provisions. Information about how we process your personal data can be found in our Wellbee Privacy Policy.
Electronic services provided via the Wellbee Platform are delivered by us, Wellbee sp. z o.o. (“we,” “us,” “our,” “Wellbee”), with its registered office in Warsaw (00-020), ul. Chmielna 2/31, entered in the Register of Entrepreneurs of the National Court Register under number KRS: 0000867078, NIP: 5252831565, REGON: 386648532, with a share capital of PLN 38,100. Therapeutic services are provided by Wellbee Therapy sp. z o.o., one of the entities within our corporate group (further details about this can be found later in these Terms).
We make these Terms and other service conditions available to everyone (free of charge, of course) before concluding any agreement with us. Upon request, we also provide the Terms in a manner that allows a person to obtain, reproduce, and record their content using the IT system they use.
If you have the status of a consumer (which is almost certainly the case), please remember that you have numerous rights granted by applicable laws. None of the provisions of these Terms should be interpreted as limiting those rights.
Remember that by accepting these Terms, you agree to use the Platform and our services as intended, and in compliance with applicable laws and the social norms prevalent in our society.
Below, you will find some definitions used in the subsequent parts of these Terms—we assume this format will facilitate your understanding of the document:
Consumer – any User using the Platform for purposes not directly related to their business or professional activity; this also applies accordingly to entrepreneurs with consumer rights.
Account – a free electronic service we provide to you, consisting of access to a dedicated and customizable section of the Platform, enabling you to use other Services.
Materials – various types of recordings, texts, psychometric tests, or other materials concerning broadly understood mental health, which constitute digital content accessible by purchasing via the Platform.
Newsletter – one of the Services, involving sending digital content to your email address, containing information related to mental and physical health initiatives, our activities, or updates available on the Platform.
Fee – the amount you must pay to use a Therapeutic Service or gain access to Materials; we do not apply hidden Fees, and each Material or Service is always clearly indicated as requiring a specific Fee.
Platform – the Wellbee website and all its functionalities enabling access to the Services, including Therapeutic Services.
Terms – this document describing, among other things, your and our rights and obligations.
Force Majeure – an event which could not have been foreseen despite exercising due care, external both to you and us, which could not be resisted despite acting with due diligence; examples include hacking attacks, acts of public authorities, natural disasters, or malware infections of the Platform.
Specialist – an individual possessing the appropriate qualifications (e.g., psychologist, psychotherapist, dietitian), indicated on the Platform, providing Therapeutic Services to you under the Therapeutic Services Agreement.
Agreement – an agreement for the provision of Services you enter into with us by accepting the Terms, including the Therapeutic Services Agreement according to the Terms, if you purchase Therapeutic Services via the Platform.
Therapeutic Services Agreement – an agreement for Therapeutic Services concluded via the Platform between you (as the User) and Wellbee Therapy sp. z o.o., with its registered office in Warsaw (00-020), ul. Chmielna 2/31, entered into the Register of Entrepreneurs of the National Court Register under number KRS: 0000881219, NIP: 5252837852, REGON: 38698317600000, with a share capital of PLN 5,000, belonging to the Wellbee corporate group.
Services – electronic services we provide to you through the Platform's functionalities, particularly the Account service and—if you choose to—access to Materials or psychological tests.
Therapeutic Services – consultations with psychologists, psychotherapists, psycho-dietitians, and other professionals listed on the Platform, which you can purchase using the Platform’s functionalities; Therapeutic Services are provided by Wellbee Therapy.
User – an identified individual with full legal capacity who uses the Platform and enters into an Agreement or Therapeutic Services Agreement with us.
Wellbee Therapy – the entity with which you enter into a Therapeutic Services Agreement, with registration details as specified above.
These Terms form the basis of the relationship between you and us, outlining your rights and responsibilities, as well as ours. They also describe certain procedures, such as handling complaints, breaches of law, or sharing your personal data with Specialists. Additionally, they regulate the terms of the Therapeutic Services Agreement.
Polish law applies to all Agreements—this means that any issues not covered by these Terms will be governed by applicable Polish regulations, including provisions of the Polish Civil Code or the Consumer Rights Act.
The Platform does not present offers made in electronic form as defined by applicable regulations. Therefore, please be aware that the rules related to electronic offer submissions do not apply.
If you have any questions or wish to communicate with us for any reason, you can reach us via email at opiekun@wellbee.pl or by phone at 732489003. We will respond to your queries as quickly as possible.
You may also contact us using the chat feature available on the Platform.
PLATFORM
To use our Platform, your equipment must meet certain basic requirements, which allow for usage on most modern devices. These include:
The Platform, insofar as it provides digital services or digital content, may utilize your digital environment (network connection, software, and hardware) to the extent necessary for the proper provision of Services. Depending on the Service or Therapeutic Service, this may involve using:
You can access our Platform from all standard devices such as tablets, computers, and smartphones. However, we do not guarantee that it will be accessible from other devices not typically intended for web browsing, despite internet access.
Additional technical requirements are detailed in the "Therapeutic Services" section of the Terms. These apply only if you use Therapeutic Services.
Remember that you must use the Platform in accordance with these Terms and applicable laws. Violating these rules allows us to take actions outlined in the "Breach of Terms" section.
Other people, including Specialists and Users, also use the Platform. Therefore, you must not:
The Platform and all its components (including design, logos, and other trademarks) are protected by intellectual property rights (including copyrights and industrial property rights), and may constitute registered trademarks or designs. You are not authorized to copy, reproduce, or distribute them without our explicit consent. Doing so would necessitate legal action to protect our rights.
After creating an Account, you may receive messages from us via email. These may include information about changes to the Terms, Services, new features, and promotions (more details in the "Newsletter" section).
ACCOUNT
To enter into a Service Agreement with us, including the possibility of concluding a Therapeutic Services Agreement, you must create an Account (excluding Materials and Platform functionalities available without an Account). Information required to set up your Account is available on the Platform.
Please note that the provisions of consumer law do not apply to the Account service, as we provide this service solely based on your personal data, which is processed only to provide you with Account access.
Your Account includes information you provided during registration. You are responsible for maintaining the accuracy and up-to-date status of this information, updating it as needed through the Account functionalities.
You cannot transfer any rights or obligations associated with your Account without our clear and explicit consent.
OUR SERVICES
We offer various Services on the Platform, the most important being:
Services, excluding access to certain Materials and Therapeutic Services (defined as separate services), are provided free of charge. This means we do not charge fees for these Services.
Depending on the Service type, it will be accessible after registering an Account, making payments through the Account, or without creating an Account by using the Platform's available options.
The Service providing access to Materials does not allow you to create or co-create content.
Through the Materials Service, we provide various digital content accessible via the Platform. Access is granted upon logging into the Account used to purchase the Materials. We may also offer you a trial period free of charge.
When you enter into an Agreement for paid access to Materials (digital content), we guarantee:
Detailed descriptions of each Service are available on the Platform. We may introduce new Services without altering these Terms unless necessary due to the nature of the new Service.
The service involving contact with a therapy advisor includes a telephone consultation to analyze your therapeutic needs. Your personal data will be processed solely to facilitate this contact. This service may be free or paid, clearly communicated to you before initiating contact. If paid, the fee you pay for this service will be deducted from your first Therapeutic Service.
If the therapy advisor service mentioned above is paid, you are entitled to rights relating to Therapeutic Services as specified in these Terms. Thus, the provisions regarding Therapeutic Services, especially concerning fees and cancellations, apply accordingly.
If you order a Service (including a Therapeutic Service) subject to consumer regulations, we will provide required legal information no later than when you express your intent to enter into the relevant Agreement.
MATERIALS
Please remember that all content or tests available within the Materials are solely informational and exemplary, aimed at improving quality of life. They are in no way intended to replace or serve as an alternative to medical advice, diagnosis, or treatment for any condition or disorder.
Be aware that the creators of the Materials do not know your health condition, have no knowledge of how your body functions, nor are they aware of any potential disorders you may have. Therefore, you should never rely solely on information provided in the Materials, and any issues related to your health should always be personally consulted with a qualified professional.
By accessing the Materials, you acknowledge and agree that you will not make decisions, take actions, or refrain from actions related to your health condition based solely on the Materials. If necessary, always contact a doctor or other qualified professional before making any health-related decisions.
NEWSLETTER
Please note that when you use our Newsletter service, consumer protection regulations do not apply, as this service is provided based on your consent and involves processing your personal data solely for the purpose of sending the Newsletter.
You can unsubscribe from the Newsletter service at any time by contacting us via email at opiekun@wellbee.pl or using the unsubscribe link provided in each Newsletter message.
THERAPEUTIC SERVICES
When choosing online Therapeutic Services, you must have a device with stable, high-quality internet access (since simultaneous audio and video are required), and access to Google Meet software. Using another application for transmitting voice and video between devices is possible only under exceptional circumstances, and only with the explicit agreement of both parties to the Therapeutic Services Agreement—you and the Specialist or Wellbee Therapy.
If you choose in-person Therapeutic Services, you must appear at the location indicated by the Specialist on the Platform. This location will always be shown before you conclude the Therapeutic Services Agreement. Please note that in-person Therapeutic Services are not available for services provided by psychiatrists.
Specialists delivering Therapeutic Services on behalf of Wellbee Therapy maintain high-quality service standards and are obliged to adhere to the Ethical Code of the Polish Psychological Association, confidentiality obligations, and applicable laws, including data protection and privacy policies. They also possess appropriate education, licenses, and experience, verified by Wellbee Therapy during recruitment and continuously monitored throughout the cooperation period. However, Wellbee and Wellbee Therapy are not responsible if a Specialist deliberately misleads us, provides false statements, or otherwise influences our decision to publish information about their Therapeutic Services.
If you have concerns about the quality of Therapeutic Services, you should contact Wellbee. According to agreements between Wellbee and Wellbee Therapy, Wellbee handles complaints and other inquiries. Please note that we are responsible for Specialists and their actions only within the scope specified in these Terms (this applies to both Wellbee and Wellbee Therapy). It is also good practice to discuss your concerns directly with the Specialist handling your Therapeutic Service.
Remember that for online sessions with a Specialist, turning on both the microphone and camera is mandatory. Without these, the online Therapeutic Service cannot take place.
We want both you and our Specialists to feel completely safe while using our Platform and Services. Therefore, we clearly specify behaviors that are unacceptable.
Like Specialists, you are required to follow good manners in the context of Therapeutic Services, especially ensuring punctuality, transparent communication with the Specialist regarding changes to session schedules, maintaining appropriate conditions for sessions (quiet, calm, absence of other people in the room), and respecting etiquette, including not recording sessions without prior notification and explicit consent from the Specialist. Additionally, you must avoid any sexual or explicitly erotic, vulgar, offensive, intimidating, or privacy-infringing behaviors, particularly towards Specialists.
Failure to comply with these conditions, or if their fulfillment is necessary to conduct the Therapeutic Service and is your fault, may result in the Specialist refusing to perform the Therapeutic Service without a refund. Violation of these conditions may also result in further actions outlined in the section titled "Breach of Terms," potentially without prior warning.
COMMENTS
If we provide such functionality on the Platform (which we do not guarantee), you are entitled, just like other users, to add comments related to the Specialists' competencies and the quality of Therapeutic Services they provide. If the option to add comments is available, you agree to comply with the following rules for every comment you publish on the Platform.
Please remember that the comments you publish must not infringe the rights of third parties, in particular:
You will not be able to post comments if you have not used a Therapeutic Service provided by a particular Specialist. Even if the Platform's functionality enables you to do so, you commit not to do it—to ensure the accuracy of information in the comments, helping other users decide if they wish to book a session with a specific Specialist.
We reserve the right to delete comments that violate applicable laws or the Terms of Service. Removal of a comment will always follow an evaluation. If we have doubts regarding the content of your comment, we may contact you for clarification.
We will take measures to ensure comments contain only truthful or objectively evaluative content. Nevertheless, you always independently decide on your choice of Specialist—we are not responsible if you rely solely on the comments.
If you have purchased access to Materials, you can also post comments on specific content or ask questions to experts—Specialists—whose answers are published on our Platform. All the rules described in this section apply accordingly to comments under specific Materials.
FEES AND CANCELLATION OF APPOINTMENTS WITH A SPECIALIST
In cases where a Service or Therapeutic Service requires payment, you can pay by: i) using functionalities that allow immediate online payment transfers, or ii) regular or online bank transfers to our bank account, provided this method is only possible if the immediate payment option is unavailable. You will be informed of all details before placing an order.
The Therapeutic Services Agreement is concluded under the condition that payment is made at least 24 hours before the scheduled Therapeutic Service. If payment is not made within this period, the Therapeutic Services Agreement is considered void.
Due to the 24-hour payment policy, you may cancel a Therapeutic Service no later than 24 hours before its scheduled time. After this period, the Therapeutic Service is no longer available for anyone else, and therefore you will not be eligible for a refund if you do not attend the appointment. This also applies to rescheduling appointments, which must also be done at least 24 hours in advance. This provision may be subject to changes based on terms agreed individually with a Specialist in a separate therapeutic contract, which is independent of us.
Fees on the Platform are not individually adjusted based on automated decision-making processes. However, please note that fees directly incurred by individual Users may differ.
Such price differences might result from agreements with employers or other entities associated with the User, who partially cover the cost of a specific paid Service. Therefore, the final price for access to Materials or Therapeutic Services remains consistent, regardless of how much of it is paid by the User.
Additionally, in some cases, we may offer discounts—for example, by providing a promotional code during the order process. In such cases, we will inform you about the lowest price for the Service (including Therapeutic Services) within the past 30 days or, if the Service has been offered for a shorter period, from the time it was first introduced on the Platform.
If you choose subscription-based access to Materials, you may consent to recurring payments, meaning automated payments charged to your chosen payment card for each subscription period selected on the Platform. You can easily cancel recurring payments at any time via the Platform's functionalities. Please remember, however, that cancellation will block access to Materials after the end of the last paid period.
Remember that if you lose the right to withdraw from the Agreement in cases specified on the Platform and described in the Terms of Service (particularly if you explicitly accept losing this right), you will not be eligible for a refund (for example, if the Therapeutic Service has already been provided).
RESPONSIBILITY
We are responsible for ensuring the proper technical operation of the Platform and access to Services, including Materials.
On the Platform, Therapeutic Services are provided exclusively by Specialists who have an appropriate agreement with Wellbee Therapy. Wellbee is not responsible for the actions or omissions of Specialists.
We assume full responsibility for the compliance of our Services, including the Platform, with the Agreement and our explicit assurances.
However, we are not liable for damages resulting from your fault or under the following circumstances:
As a Platform user, you are responsible to us and Wellbee Therapy for your actions and omissions when using the Platform and during Therapeutic Services.
You are also responsible for not causing harm to us, particularly by engaging in artificial, unfair, or illegal actions aimed at reducing payments for Therapeutic Services. If your actions cause financial damage to us, you agree to reimburse us for the full value of any discounts or unauthorized benefits you have obtained—this includes situations where discounts are granted to employees or partners, and you are not among them.
Consumer Rights
Within the Platform, we will provide you with various information that you are entitled to receive under applicable law. We will inform you, among other things:
Whenever you order a Service (paid) or Therapeutic Service via the Platform, we will confirm the conclusion of the Agreement regarding the specific Service or Therapeutic Service before its commencement.
Wellbee Therapy, in providing Therapeutic Services, operates as an entrepreneur.
Withdrawal or Termination of the Agreement
You have the right to withdraw from the Agreement (regarding Services or Therapeutic Services) without giving a reason by submitting a withdrawal statement to us (via email, provided it is the same email address you used to create your Account) at opiekun@wellbee.pl, through the Platform, or in writing to our address.
The deadline for withdrawal from the Agreement is 14 days from the date of its conclusion. Sending the withdrawal statement before this deadline expires is sufficient.
Along with the confirmation of the conclusion of the Agreement (including the Therapeutic Services Agreement), we will send you a model withdrawal form, which is also attached to the Terms. You can exercise your right of withdrawal using this form.
Remember, in certain cases, you will not have the right to withdraw from the Agreement. For example, this applies when the Agreement covers access to Materials, i.e., digital content not saved on a physical medium, provided you previously agreed to receive such content before the withdrawal period expired through Platform functionality, as per Art. 38 para. 1 point 12 of the Consumer Rights Act.
If you do not provide the above-mentioned consent, access to the Materials will be granted only after 14 days from their purchase date.
When concluding a Therapeutic Services Agreement, remember that these are healthcare services provided by healthcare professionals to patients for assessing, maintaining, or improving their health. Consequently, only the following provisions of the Consumer Rights Act will apply: Art. 12 para. 1 points 1-12 and para. 2, Art. 13, Art. 14, Art. 15 para. 1 and 3, Art. 19, Art. 21-24, Art. 26-37, and Art. 38 points 1, 3-6, and 8.
If you purchase Therapeutic Services, you must consent to the loss of your right to withdraw from the agreement after the Therapeutic Service has been provided, according to Art. 38 para. 1 point 1 of the Consumer Rights Act.
Depending on your choices on the Platform, you may enter into a psychotherapeutic contract with a Specialist, potentially long-term, tailored to your individual therapeutic needs and goals.
In the case of the Therapeutic Service mentioned above, you have the right to withdraw from the Therapeutic Services Agreement within 14 days from its conclusion; however, such withdrawal will not cover sessions already conducted before we receive your withdrawal statement.
If you wish to terminate the Therapeutic Services Agreement, both you and the Specialist are entitled to terminate it with a 14-day notice. You can submit such a statement via our Platform. This arises from the specifics of psychotherapeutic contracts and good practices in mental health care. We also ask you to inform the Specialist directly about your intention to end long-term cooperation.
Neither Wellbee nor Wellbee Therapy can guarantee that a particular Specialist will be able to provide Therapeutic Services for the entire period you require. If a Specialist can no longer provide Therapeutic Services for any reason, you will be promptly informed. In such a case, you may: i) contact a therapy advisor to change Specialists, or ii) resign from Therapeutic Services, thereby immediately terminating the Therapeutic Services Agreement (we will then refund payments for services not yet rendered).
In the case of long-term Therapeutic Services, fees may need to be adjusted. If fees have been individually agreed with you (and Terms provisions regarding fee changes do not apply), your consent is required for such changes. If you do not consent, the Specialist may decide to cease providing Therapeutic Services to you, effectively terminating the Therapeutic Services Agreement within a notice period specified by the Specialist (no shorter than 14 days), justified by your mental health status and the Specialist’s professional ethics.
If you withdraw from an Agreement regarding any digital content or service, you must immediately cease using and sharing such content or services with third parties.
Upon receiving your withdrawal statement, we will promptly confirm its receipt. If we believe you did not have the right to withdraw, we will inform you accordingly.
If your statement is valid, we will refund your payment within 14 days of receiving your withdrawal statement, using the same payment method you used initially.
All statements and communications regarding exercising the rights mentioned above should be directed to Wellbee, which is authorized to represent Wellbee Therapy concerning organizational aspects of Therapeutic Services Agreements.
Breach of Terms
If you culpably use the Platform contrary to the law or these Terms, we may take specific actions, such as:
We will notify you of initiating this procedure via email, clearly indicating the reasons for our decision.
Considering the above—if you purchased Therapeutic Services for a specified period and use the Platform contrary to the law or Terms, we are entitled to inform your Specialist, who may request that you cease such actions.
In case of immediate termination of Agreements regarding our Services and Therapeutic Services (without a notice period), we will refund fees paid for Services you have not yet used, particularly Therapeutic Services.
Complaints You have the right to submit complaints regarding the operation of the Platform and the Services provided through it. Your complaint should include at least your identifying information and specify your concerns and comments regarding the Platform. Complaints should be sent via email to opiekun@wellbee.pl or by mail to our registered office.
We will address your complaint within 14 business days, unless you fail to provide sufficient information to enable us to handle the complaint or to identify you. In such cases, the complaint handling period will commence from the date you provide us with the missing information. If we do not respond within the specified period, it means that your complaint has been accepted. The response to your complaint will be sent to the email address provided by you. Please note that our response to the complaint is final; however, you may take actions described in the "Dispute Resolution" section or undertake other measures permitted by law. Complaints regarding Therapeutic Services should be submitted following the same procedure outlined in point 1 above.
Dispute Resolution In the event of a dispute between you and us, you have the option to use alternative dispute resolution methods (ADR) instead of court proceedings, such as mediation, conciliation, or arbitration. A list of institutions you may contact for dispute resolution through ADR can be found at this link: https://uokik.gov.pl/rejestr_podmiot_uprawnionych.php.
You may also use alternative dispute resolution through the EU Online Dispute Resolution (ODR) platform, available at: http://ec.europa.eu/consumers/odr/.
If you decide not to use ADR or ODR, all disputes arising between you and us will be settled by a court with jurisdiction determined in accordance with applicable laws.
Personal Data and Confidentiality All information regarding how we process your personal data as a data controller can be found in our Privacy Policy. This policy applies to the processing of personal data by both Wellbee and Wellbee Therapy. All Specialists are obliged to maintain confidentiality regarding your personal data and any other information obtained from you. This obligation stems from legal regulations (professional confidentiality) or agreements concluded by individual Specialists. We commit to maintaining the confidentiality of all User information obtained in connection with the use of the Platform. Such information will be used solely for the purpose of providing Services and will not be shared with third parties without your explicit consent unless required by applicable law.
Technical Efficiency of the Platform We will make every effort to ensure the proper functioning of the Platform. We guarantee the continuity and functionality of the Platform. However, please note that this does not include events and consequences resulting from Force Majeure, server operators, or other external software providers. To improve service quality and ensure the Platform operates effectively, we will occasionally perform maintenance or upgrades, including updates. As a result, technical interruptions in access to the Platform may occur, not exceeding 3 hours per month.
Information on Specific Risks Associated with Using Electronic Services Using electronically provided Services involves several potential risks, such as:
To mitigate these risks, we recommend equipping your computer and electronic devices used to access the Platform with regularly updated antivirus software and a firewall. Additionally, your email should have virus detection software to scan emails before opening them.
Changes to the Terms & Scope of Services We may amend these Terms for important legal (e.g., amendments to laws affecting Wellbee's operations), organizational (e.g., changes to our business model or service offering), or technical reasons (e.g., upgrades to the Platform, service changes, or new functionalities).
You will be informed of any changes to the Terms via email sent to the address registered with your Account, at least 15 (fifteen) days before the new Terms come into effect. If you do not inform us that you reject the changes, the new version of the Terms will apply to you once the notice period ends. If you do not accept the changes and notify us accordingly, we will delete your Account (our Agreement will be terminated) on the effective date of the new Terms or — if you have purchased therapeutic Services — on the date your last pre-paid therapeutic Service is provided (after which you will not be able to purchase new Services, and the unchanged Terms will continue to apply).
Even if we amend the Terms, this will not affect the Agreement in terms of access to paid elements of the Services (including but not limited to Materials) for the period you have contracted with us.
Please note that digital content (Materials) may be modified by removing or replacing certain content. These changes are made to ensure all Users have access to high-quality, informative, and engaging content, and to maintain our compliance in delivering such content. Materials may also change due to: i) updates; ii) the need to remove certain elements due to rights held by third parties. If we make changes to specific Materials, we will notify you clearly and understandably. None of the changes to the Platform will reduce the quality of the Platform or the Services.
Final Provisions The applicable law for obligations under Agreements will be Polish law, provided that this choice does not deprive Consumers of the protection afforded to them by the mandatory laws of their habitual residence.
If any provision of the Terms is found to be invalid, in whole or in part, the remaining provisions shall remain in force, and the invalid provision shall be interpreted in a way that preserves the legal and economic effect closest to the original.
Effective date of the Terms: October 31, 2024.
Withdrawal Form Template (This form should be completed and returned only if you wish to withdraw from the contract)
Recipient: Wellbee sp. z o.o., based in Warsaw (00-020), ul. Chmielna 2/31, registered with the National Court Register under number KRS: 0000867078, NIP: 5252831565, REGON: 386648532, with a share capital of PLN 38,100, email: opiekun@wellbee.pl, phone number: +48 732 489 003
I/We() hereby inform you of my/our() withdrawal from the contract for the sale of the following goods() / contract for delivery of the following goods() / contract for the performance of the following work() / for the provision of the following service():
I/We withdraw from the contract dated* ... regarding* ...
Date of contract()/receipt() Name and surname of the consumer(s) Address of the consumer(s) Signature of the consumer(s) (only if the form is sent in paper form) Date
(*) Delete as appropriate.