User Registration
Login Name: *
Password:  *
Confirm Password: *
Personal Contact Information
First Name: *
Last Name: *
Address:  *
City:  *
State:  *
Zip:  *
Email:  *
Date of Birth: *
Phone: *
Emergency Contacts (enter 2 persons who will NOT be travelling with you to Brazil) Contact #1 Contact #2 First Name: *    First Name:   Last Name: *    Last Name:   Address:  Address:   City:  City:   State:  State:   Zip: Zip:   Phone:  *   Phone:  Email Address: Email Address: Relationship: *    Relationship:  How did you hear about us?   Please specify an approximate date when you would like to have surgery (MM/DD/YYYY):   Approximately how much time will you have available to stay in Brazil?   Release and Waiver of Liability   Before registering you must read and agree to the Release and Waiver of Liability.   Click Here to read the Release and Waiver of Liability.   If you decide to have surgery, you will be required to print and mail a signed and notarized copy of this form to TLC Medical Travel Services, LLC. If you agree to the conditions outlined on the Release and Waiver of Liability, click the check box below to continue the registration process. I accept these terms and conditions.