Medical Tourism - Application For Membership

Application For Membership

* Required Fields

First Name *:
Last Name *:
Street Address *:
City *:
State *:
Zip *:
Country *:
Daytime Phone *:
Evening Phone :
Cell Phone :
Fax :
Email Address *:
Please Confirm Email *:
1st Procedure:
2nd Procedure:
3rd Procedure:
4th Procedure:
5th Procedure:
6th Procedure:
7th Procedure:
8th Procedure:
9th Procedure:
10th Procedure:
11th Procedure:
12th Procedure:
Age :
Preferred Destination:
When are you planning to travel abroad?:
Do you have a passport? *:	Yes No
When considering your medical retreat, what is most important to you? Please rank in order of importance (select a criteria and then move it Up or Down) with the most important on top.*

Other (please specify) :
How did you hear about MedRetreat? *:
General Questions or Comments :
Terms and Conditions:	Welcome to the MEDRETREAT website provided by MEDRETREAT, LLC. Our Terms & Conditions spell out your access to and use of this Site and the information, and other content available on or through this Site. Please read these Terms & Conditions carefully before using this Site. We reserve the right, at our sole discretion, to change our Terms & Conditions from time to time. Your continued use of this Site after such changes take effect will be deemed to constitute your acceptance of our new Terms & Conditions. BY ACCESSING, USING OR BROWSING THIS SITE OR ANY OF THE TABS, PAGES, OR WINDOWS IN THIS SITE, YOU INDICATE THAT YOU HAVE READ, UNDERSTOOD AND AGREE TO BE BOUND BY THIS AGREEMENT, AND THAT YOU UNDERSTAND AND INTEND THIS USER AGREEMENT TO BE THE LEGAL EQUIVALENT OF A SIGNED, WRITTEN CONTRACT BETWEEN YOU AND MEDRETREAT, LLC, AND EQUALLY BINDING. Description of Service MEDRETREAT, LLC is the leading medical tourism service agency in the United States specializing in medical treatment and recuperation packages for destinations outside the continental United States. In this role, we research and gather publicly available information and provide this information to you for your personal use in making a more informed decision about your medical treatment options outside the US. Not A Medical Referral Service MEDRETREAT, LLC is not a medical referral service and does not endorse, recommend, or approve any travel agency or healthcare provider listed in the Site. We are not medical professionals and will not discuss or advise any issues relating to medical treatment. We facilitate contact with, and provide information about doctors outside the US and provide information about their credentials in order for you to make informed decisions. We do not, however, recommend any preferred or specific doctors for your desired medical treatment. We encourage and advise you to discuss all medical issues with your medical doctor in the United States, before making a decision on medical treatment outside the United States. Through our medical tourism affiliates around the world and our in-depth research we provide information about available medical treatment and recuperation and packages to assist you making an informed decision. You agree to assume all responsibility in connection with choosing any doctor for your desired procedure. We assume no responsibility or liability for any treatment or other services rendered by any doctor, or for any malpractice claims and other claims that may arise directly or indirectly from any such advice, treatment or other services. Disclaimers THIS SITE IS FOR INFORMATIONAL PURPOSES ONLY. AS WE STRIVE TO PROVIDE THE MOST ACCURATE, UP TO DATE INFORMATION POSSIBLE, THE SITE MAY CONTAIN TECHNICAL INACCURACIES OR TYPOGRAPHICAL ERRORS, AND MAY BE CHANGED OR UPDATED WITHOUT NOTICE. TO THE FULLEST EXTENT PERMISSIBLE PURSUANT TO APPLICABLE LAW WE ASSUME NO RESPONSIBILITY NOR DO WE GRANT ANY WARRANTIES, EXPRESS OR IMPLIED RELATING TO THE OPERATION, SAFETY, CONDITION OR SERVICE OF ANY PHYSICIAN, HEALTH CARE PROVIDER, HOSPITAL, AIRCRAFT, MOTOR VEHICLE, BOAT, OTHER CONVEYANCE, INN, LODGE, OR HOTEL AND/OR PRODUCTS ASSOCIATED WITH SUCH ENTITIES OR SERVICES THAT ARE USED WHOLLY OR IN PART BY, FOR OR ON BEHALF OF YOU. WE ARE NOT LIABLE FOR THE ACTS, ERRORS, OMISSIONS, REPRESENTATIONS, WARRANTIES, BREACHES OR NEGLIGENCE OF ANY SUCH SUPPLIERS OR FOR ANY PERSONAL INJURIES, DEATH, PROPERTY DAMAGE, OR OTHER DAMAGES OR EXPENSES RESULTING THEREFROM. Limitations of Liability YOU AGREE THAT NEITHER WE NOR OUR INTERNATIONAL AFFILIATES WILL BE LIABLE FOR ANY DAMAGES RESULTING FROM YOUR USE OF, OR RELIANCE UPON, THIS SITE, ANY SITE MATERIALS, OR ANY SERVICES OBTAINED ON OR THROUGH THIS SITE. IN THE EVENT OF ANY PROBLEM WITH THIS SITE, ANY SITE MATERIALS, OR SERVICES OBTAINED ON OR THROUGH THIS SITE, YOU AGREE THAT YOUR SOLE REMEDY IS TO CEASE USING SUCH ITEMS. YOU AGREE THAT UNDER NO CIRCUMSTANCES WILL MEDRETREAT, LLC OR ANY OF OUR OR THEIR DIRECTORS, OFFICERS, MEMBERS, EMPLOYEES, AGENTS, REPRESENTATIVES, SERVANTS, ATTORNEYS, PREDECESSORS, SUCCESSORS OR ASSIGNS, BE LIABLE FOR ANY INDIRECT, INCIDENTAL, SPECIAL, PUNITIVE, EXEMPLARY OR CONSEQUENTIAL DAMAGES (INCLUDING, BUT NOT LIMITED TO, LOST PROFITS AND DAMAGES THAT RESULT FROM INCONVENIENCE, DELAY, OR LOSS OF USE) ARISING OUT OF USE OF THIS SITE, ANY SITE MATERIALS, ARRANGEMENTS MADE BASED ON INFORMATION OBTAINED ON OR THROUGH THIS SITE, OR PRODUCTS OR SERVICES OBTAINED ON OR THROUGH THIS SITE, EVEN IF WE OR THEY HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. Indemnity You agree to defend, indemnify, and hold harmless MEDRETREAT, LLC and our affiliates, and our and their respective directors, officers, members, employees, agents, representatives, attorneys, successors and assigns, from and against any and all claims, proceedings, damages, injuries, liabilities, losses, costs and expenses (including reasonable attorneys' fees and litigation expenses), relating to or arising from (i) your use of this Site, any Site Materials, or services obtained on or through this Site, (ii) any arrangements you make based on information obtained on or through this Site, or (iii) any breach by you of our Terms & Conditions. Venue You agree that this User Agreement shall be governed by and construed in accordance with the law of the State of Maryland. We agree that any legal action or proceeding under or with respect to this agreement may be brought in the courts of the State of Maryland or the United States having jurisdiction in Anne Arundel County; and for the purpose of any such legal action or proceeding, you hereby submit to the jurisdiction of such courts. You hereby agree not to raise and waives any objection to or any defense based upon the venue of such courts and any objection or defense based upon an inconvenient form. You also agree not to bring any legal action or proceeding under or with respect to this agreement outside Anne Arundel County, Maryland unless, for some reason, the courts of the State of Maryland and the federal courts having jurisdiction in Anne Arundel County refuse or do not have jurisdiction in the matter. Arbitration Except as otherwise expressly provided in this User Agreement, any dispute or claim arising under or with respect to this User Agreement will be resolved by arbitration under the provisions of the Maryland Arbitration Act (Courts and Judicial Proceedings Article, Section 3-201, et seq., as amended from time to time). The arbitrator in any proceeding may award reasonable costs and expenses, including reasonable attorneys’ fee, to the prevailing party. Copyright and Ownership Copyright © MEDRETREAT, LLC All Rights Reserved All of the Site Materials, including the content and display of this Site are the property of MEDRETREAT, LLC. The Site Materials are protected by law, including, but not limited to, United States and international copyright law and trademark law, as well as other state, federal, and international laws and regulations. Other names and logos contained in this Site or in the Site Materials are trademarks and service marks of our affiliates and may not be used without the permission of the trademark or service mark owner. Privacy Policy The information that we collect from our users is used only to facilitate the selection of desired destination and medical procedure. We do not sell or share your information to any third party at any time without your permission. The protection of our users' personal information is extremely important to us. Therefore, we have adopted a privacy policy outlining our personal information collection and use practices. Please refer to it for details about how we collect and use personal information from users of this Site. Any changes to the Privacy Policy will be posted on this Site, and you should periodically consult this Site to stay apprised of any such changes. Links to Other Sites This Site contains links to other sites on the World Wide Web for the convenience of our users. These other sites are maintained by third parties over whom we exercise no control. Accordingly, we expressly disclaim any responsibility for the content of these other sites and for the availability, accuracy, reliability, completeness, currency, quality, performance or suitability of the information, products and services available or advertised on or through these other sites. Payment Terms All participants will be required to make payment through certified or personal check in order to confirm all bookings. Four weeks prior to departure, a 20% deposit of the total procedure price will be required to reserve booking. The Gold Club Membership (GCM) fee, which entitles the participant to receive priority service, is non-refendable.and non-transferable. Please do not apply for the GCM unless you are absolutely certain of your interest in MedRetreat's services. Cancellation & Changes Because of the special nature of the medical and tour packages featured in this Site, our affiliates may impose variable cancellation fees. You agree that MEDRETREAT, LLC has no control over such fees and cannot consider making any exceptions to these charges. Airfares are subject to different rules and cancellation fees; some maybe non-refundable. To protect against cancellation charges, we strongly recommend purchasing Cancellation Protection and Travel Interruption Insurance. Travel Documents All participants must be in possession of a valid passport during time of travel. Depending on length of visit, a Visa or may be required for some or all of the countries visited. Please check your visa requirement at time of booking. MEDRETREAT, LLC will provide visa information when applicable. Prices, Rates, and Fares Unless otherwise indicated all prices rates shown are in United States Dollars and are per person. These prices are in effect for 2008 and are subject to change at any time prior to departure. MEDRETREAT, LLC 2042 Laurel Valley Drive Vernon Hills, IL 60061 Tel: 1-877-876-3373 Fax: 1-847-680-7788 www.medretreat.com
	I agree to the Terms and Conditions *:



Copyright © 2011 MedRetreat. All rights reserved.	Site Map \|Terms and Conditions \| Privacy Statement	America's Medical Tourism Company