Patient Eligibility Form

Filling out this form can be the first step to improving your quality of life! (Please read the following instructions carefully.)

  • The information you provide to us is confidential; we do not share or distribute this data as it is used for medical purposes only.
  • It is very important to disclose any medical information, especially anemia, diabetes, or any blood abnormality.
  • If you have had a previous bariatric surgery, please elaborate on which procedure you had, your initial weight loss, and when you had it. Please provide these details in the "Other" section.
  • If your previous bariatric surgery was not laparoscopic (open), please let us know by using the "Other" section.
  • Financing is available. If you would like to receive more information, please indicate so in the "Other" section.
  • You will receive detailed information about your inquiry via email and a one-time text message. If you have a preferred method of contact (email, text, or call), please let us know by replying to our email or text.
  • WE DO NOT charge for providing you with any information, and if you choose to have a virtual consultation, it is also at no cost to you.

* = required

Body Mass Index

Height *

Obesity Related Problems




Bone Problems


Sleep Disorders

Physical Condition

Digestive System

Heart and Circulatory System

Respiratory Problems

Compulsive Eating

Low Expectations


Gastro Esophageal Reflux

Hiatal Hernia

Dr. Sandy Martinez at her office

Dr. Sandy Martinez

Dr. Sandy Martinez is a double board-certified bariatric surgeon in Tijuana, B.C. who helps patients achieve their weight loss goals by providing compassionate and high-quality care. She is affiliated with many organizations, including:

  • National Board of Surgery Mexico
  • National Board of Bariatric Surgery
  • Baja California Board of Bariatric Surgery
  • American Society of Bariatric Surgery
  • American Society for Metabolic and Bariatric Surgery
  • International Federation for the Surgery of Obesity and Metabolic Disorders

For more information on the services we offer or to request a consultation, we invite you to call our practice at (619) 484-9903.

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