2025 Louisiana Obesity Conference
Registration Form
Name
*
First Name
Middle Initial
Last Name
Suffix
I am a member of
*
LA-ASMBS
LOS
Both
Non-Member
Register me as:
*
Physician/Surgeon
IH Member
Dietitian
Retired
Resident
Medical Students
Trainee
Fellow
Speaker
Other
Choose all that apply
MD
DO
FACS
FASMBS
RN
LPN
CRNP
APRN
MSN
RD
LD
PA
PhD
Other
Work Title
*
Practice/Program
*
City/State
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Registration Information
Day(s) Attending:
*
Friday, August 8, 2025
Saturday, August 9, 2025
Both Days
Are you having lunch on Friday?
*
yes
no
unsure
Are you having lunch on Saturday?
*
yes
no
unsure
Networking Event on Friday, August 8th
*
yes
no
Breakout Sessions
Which afternoon session will you attend
*
LA-ASMBS Breakout
LOS Breakout
Not attending the breakout sessions
Dietary Restrictions
Dietary Restrictions
LOS Membership
Please send me information to join/renew LOS?
*
yes
no
Late Registration Fees
Late Registration Fees
*
prev
next
( X )
Late Registration Fee
$
250.00
Industry
$
400.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
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