Clone of All-Inclusive Membership Sign-Up Form

Please use this form to sign up for your Premium All-Inclusive Membership Plan at TOM Weight Loss. Everything you need for your weight-loss journey is included, and there are no hidden fees.

If you have questions or concerns about the membership process, feel free to reach us at contact@mytomclinic.com or 713-568-9102.

If you have not yet completed a Free Consultation with Dr. Le, please complete the Free Consultation Form after you finish this sign-up. The consultation is included in your membership.
Membership is only available for residents of Texas and Utah!
Membership will automatically renew every month.
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.

Where did you find TOM Weight Loss?

Full Name

First NameLast Name

Date of Birth (you must be at least 18 years old to sign up for membership)

Date

Address

Street Address

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Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Choose the membership option that works for you!

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 weight loss medical care including any dose of prescribed medication for qualified patients.

$249 for each month

Payment Methods

Credit Card

Cash App Pay

Afterpay

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.

I understand that I must complete a New Patient Consultation with Dr. Le by email, phone, or video before any treatment will be provided. If I do not qualify for treatment, my membership fee will be refunded.

I understand that membership is billed automatically once a month.

I consent to the TOM Weight Loss Terms & Conditions, Privacy Policy, and Medication Refund & Return Policy, linked above.

If the green submit button is not visible below, please go back and make sure that you have answered every question with an asterisk (*) on the form above. Once you click submit, you will be redirected to the medical history form. Please complete it and Dr. Le will get back to you with your medication recommendation and prescription (if qualified) within 12 hours.

All-Inclusive Membership Sign-Up Form

Choose the membership option that works for you!*

Payment Methods

Choose the membership option that works for you!