LOS Dues Form
January 1, 2025-December 31, 2025
About You
Membership Type
*
Please Select
Physician/Surgeon
Non-Physician
Industry
Trainee (medical student/resident)
Full Name
*
First Name
Middle Name
Last Name
Suffix
Your Credentials (for example: MD, MBBS, DO, PhD, RN, APRN, RD etc.)
*
Your Profession
*
Please Select
Advance Practice Providers
Bariatric Coordinators
Behavioral Health Specialists
Clinic Coordinator
Clinic Manager
Clinical Reviewers
Exercise Physiologists
Nurses
Pharmacologists
Physical Therapists
Physician Assistant
Registered Dietitians
Researchers
Scientists
Technicians
Other
Other
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.
I am a....
*
Please Select
medical student
resident
Your Admin
Do you have an administrator we should copy on all your emails?
Please Select
yes
no
Name
First Name
Last Name
Their Title
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Join a Committee
Get Involved with LOS!
Check which committee you are interested in joining.
Advocacy
APP
Behavioral Health
Communications
Membership Committee
Nutrition
Peds
Education
Finance
Dues Receipt
We will be happy to send you an email receipt for your dues. We will email your receipt to the one provided or the person of your choice. Just provide their email address after selecting other below.
If you need an email receipt, where should we send it? (check all that apply)
myself
your admin
Other
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Physician/Surgeon Membership
$
100.00
Non-Physician Membership
$
50.00
Industry Membership
$
200.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
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