• All-Inclusive Membership Sig-Up Form

    Use this form to sign up whenever you are ready!
    All-Inclusive Membership Sig-Up Form

  • Thank you so much for joining our clinic! We want to ensure that you receive the personalized care you need so that you can reach your health goals safely and effectively. Please use this form to select the membership plan you are interested in. If you still have questions or concerns about the membership process, please always feel free to reach us at contact@mytomclinic.com or 713-568-9102.

    • If you have not yet completed your Free Consultation with Dr. Le, please complete the Free Consultation Form after you finish this sign-up. 
    • Membership is only available for residents of Texas and Utah!
    • Membership will automatically renew every 30 days or 90 days with payment charged to the card on file.
    • Please send an email to contact@mytomclinic.com for changes to payment method, changes to membership plan, or membership cancellation (please contact us at least 3 days before your next membership payment is due for cancellations).
    • Refer to our membership page for details on which memberships and medications.
  • Format: (000) 000-0000.

  • Choose the membership option that works for you!*

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    One Month All-Inclusive Basic Membership (autopay). 24/7, non-emergency access to Dr. Le through secure messaging with guaranteed response within 12 hours; all aspects of basic weight loss medical care.
    One Month All-Inclusive Basic Membership (autopay)

    24/7, non-emergency access to Dr. Le through secure messaging with guaranteed response within 12 hours; all aspects of basic weight loss medical care.

    $199$199 for each month
      
    One Month All-Inclusive Premium Membership (autopay). 24/7, non-emergency access to Dr. Le through secure messaging with guaranteed response within 12 hours; all aspects of basic weight loss medical care.
    One Month All-Inclusive Premium Membership (autopay)

    24/7, non-emergency access to Dr. Le through secure messaging with guaranteed response within 12 hours; all aspects of basic weight loss medical care.

    $249$249 for each month
      
    Three Month All-Inclusive Basic Membership (autopay). All of the same benefits of the one-month All-Inclusive Basic Membership, but receive three months of membership. Save $62!
    Three Month All-Inclusive Basic Membership (autopay)

    All of the same benefits of the one-month All-Inclusive Basic Membership, but receive three months of membership. Save $62!

    $535$535 for each three months
      
    Three Month All-Inclusive Premium Membership (autopay). All of the same benefits of the one-month All-Inclusive Premium Membership, but receive three months of medical care. Save $148!
    Three Month All-Inclusive Premium Membership (autopay)

    All of the same benefits of the one-month All-Inclusive Premium Membership, but receive three months of medical care. Save $148!

    $599$599 for each three months
      

    Payment Methods

    creditcard
    After submitting the form, you will be redirected to Cash App Pay to complete the payment.
    After submitting the form, you will be redirected to Afterpay to complete the payment.

  • Membership does not guarantee prescription of any medication. Decisions on prescriptions can only be made after consultation between you, the patient, and a licensed prescriber. Texas Obesity Medicine PLLC d/b/a TOM Weight Loss uses Square for payment collection and Square maintains sole responsibility for billing and payment collections. TOM Weight Loss does not sell, provide, deliver, or otherwise distribute medications. TOM Weight Loss connects patients with licensed medical professionals and facilitates the provision of services. Please review the TOM Weight Loss Terms & Conditions, Privacy Policy, and Medication Refund & Return Policy before continuing. 

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