LOS Membership Form
About You
Full Name
*
First Name
Middle Name
Last Name
Suffix
Your Credentials (for example: MD, MBBS, DO, PhD, RN, APRN, RD etc.)
*
Practice/Program Name
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
example@example.com
Cell Number
*
Please enter a valid phone number.
What is your medical field?
*
Please Select
Internal Medicine
Family Medicine
Medicine/Pediatrics
Pediatrics
Endocrinology
Nephrology
Cardiology
Gastroenterology
Hematology/Oncology
Psychiatry
General Surgery
Bariatric Surgery
Orthopedic Surgery
Surgical Oncology
Sleep Medicine
Other
Other medical field
Are you ABOM certified?
*
Please Select
Yes
No
No but I am planning on it in the next few years
Are you already treating obesity?
*
Please Select
Yes
No
No but I want to learn more.
Are you a member of ASMBS?
*
Please Select
Yes
No
Join a Committee
Get Involved with LOS!
Check which committee you are interested in joining.
Advocacy
APP
Behavioral Health
By-laws Chair
Communications
Membership-Chair
Nutrition
Peds
Program
Your Membership Type
Choose your membership?
*
Physician Membership - $100
Non-Physician Membership - $50
Trainee Membership (medical students, residents, etc) - No charge
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Physician Membership
$
100.00
Non-Physician Membership
$
50.00
Credit Card Details
First Name
Last Name
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Security Code
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