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Request a Consultation

While both Dr. Pope and Dr. Marino do confer with one another one all patient cases that visit our practice, Dr. Marino facilitates all of our initial consultations. Dr. Pope is only available for appointments on a limited basis and her appointments cannot be guaranteed at this time.

In-Person Consultation Request

Tele-Advice Request

Clinical Pack Request

Returning Patients

The button below can be used to book an appointment for existing patients.

Existing Client Appointment Booking

Please complete the form to get started.

"*" indicates required fields

Name*

First Last

Today's Date

MM slash DD slash YYYY

I am an existing client*

Yes

No

Are you able to come in person to the practice for a consultation?*

Our doctors are unable to establish a valid veterinarian-patient-client relationship without a physical exam, meaning that they are unable to diagnose or treat disease as well as prescribe or dispense medications.

Yes

No

STOP!

Currently we are only able to help patients that are able to be in-person for a consultation. If you are unable to travel in person to the practice for an in-person consultation we no longer provide tele-consultation services. Please be on the lookout for a new and exciting option. Kindly, Prism Integrative Veterinary Health

Address Line 1*

Address Line 2

City*

State / Province / Region*

Zip Code*

Country*

Email*

Primary Phone Number*

Your Pet's Name*

What is your pets species?*

Canine

Feline

Exotic

Your Pet's Breed*

Your Pet's Sex*

Male

Male - Neutered

Female

Female - Spayed

Unknown (exotic only)

What is your pets species?*

Small Mammal

Avian (Bird)

Reptile

Other

Please specify (small mammal)*

Please specify (avian)*

Please specify (reptile)*

Please specify*

Your pet's date of birth or age*

MM slash DD slash YYYY

How did you hear about us?*

Veterinarian

Word of Mouth

Practice Website

Internet Search

Facebook

Instagram

Other

Have you been referred to or would you prefer to see a specific doctor?*

Please specify:*

Dr. Pope

Dr. Marino

Dr. Shaw (Chiropractic)

Heather Wallace (Massage)

I am requesting an appointment for the following:*

Integrative Oncology/Integrative Medicine/Wellness

Acupuncture Only

Chiropractic Only

Unsure

You may select multiple appointment options

Integrative Oncology/Integrative Medicine/Wellness - For clients seeking comprehensive integrative and holistic care for support of cancer, chronic disease, and preventative care utilizing nutrition, herbs, supplements, and other integrative therapies. Patients can receive acupuncture during these appointments.

Thank you for your interest in our Acupuncture services! These sessions are not able to be booked online. Please call the office at 732-520-2465 so that our Client Coordinator may get you and your pet scheduled

- Acupuncture Services are for clients seeking a brief assessment and acupuncture treatment plan without comprehensive recommendations surrounding nutrition, herbs, supplements, and other integrative therapies. This does not replace a comprehensive Integrative Oncology/Integrative Medicine/Wellness consultation but is recommended for owners who are seeking a simplified approach to holistic care.

Thank you for your interest in a Chiropractic session! These sessions are not able to be booked online. Please call the office at 732-520-2465 so that our Client Coordinator may get you and your pet scheduled

- Chiropractic Sessions are for clients seeking chiropractic adjustments only. For a more holistic approach, chiropractic care can be combined with other modalities. The goal of chiropractic treatment is to increase mobility and enhance the nervous system function which after all, controls every function in the body. Veterinary referrals are required for these appointments.

Signature:*

I acknowledge and fully understand that Dr. Melissa Shaw, DC is NOT a Veterinarian. She will be performing a Chiropractic Adjustment to remove a Subluxation. This treatment is in no way a replacement for a veterinarian appointment. Dr. Melissa Shaw, DC will work together with my veterinarian to help bring my pet to optimal health. I understand the risks and understand that the outcome may not be favorable and to my expectation. I am giving my consent to Dr. Melissa Shaw, DC to provide Chiropractic Adjustments to my pet.

Witness Signature:*

Date*

MM slash DD slash YYYY

Primary Veterinarian Name:*

Veterinary Clinic:*

Primary Veterinarian Phone Number:*

What is the diagnosis/disease for which you are consulting?*

When did your pet first start showing symptoms/get diagnosed with this condition? If applicable, what are these symptoms?*

Within the last month*

Within the last 2 months*

Within the last 3 months*

Within the last 6 months*

Within the last 12 months

Within the last 18 months

More than 18 months ago

N/a - wellness

Is your pet undergoing any integrative/holistic therapies? If so, what type?*

Yes

No

What type of integrative/holistic therapies is your pet undergoing?*

Integrative Nutrition*

Herbs and Dietary Supplements*

Intravenous Nutrient Therapy*

Ozone Therapy*

Mistletoe Therapy*

Microbiome Restorative Therapy (MBRT)*

Therapeutic Massage*

Chiropractic Care*

Acupuncture*

Laser Therapy*

None of the above - n/a

Other*

Are there other veterinarians committed to treating this condition alongside our practice after consulting with us? If not, are you open to finding local veterinarians for primary/emergency care?*

Yes - I have spoken to my veterinarian about utilizing integrative methods for my pet and they are open to working with your practice*

Yes - I have not spoken with my veterinarian but am confident they will be on board with working alongside your practice*

No - my veterinarian is not open to working alongside integrative methods of treatment

No - I do not have a local veterinarian who is committed to treating my pets condition

I am unsure - I have not spoken to my veterinarian about integrative care

What have the veterinary professionals told you is your pet’s prognosis?*

(i.e. what is your pet's life expectancy given their diagnosis?)

Less than 1 month

Less than 3 months

3-6 months

6-12 months*

12-18 months*

18-24 months*

More than 2 years*

N/a - wellness*

Have you already consulted with or are you pending consultations with other conventional oncologists/specialists/veterinarians for this condition? If not, would you be open to this if recommended?*

I have consulted with a conventional oncologist/specialist/veterinarian and am going to pursue conventional treatment for my pet*

I have consulted with a conventional oncologist/specialist/veterinarian and am considering pursuing conventional treatment for my pet*

I have consulted with a conventional oncologist/specialist/veterinarian and I do not plan to pursue conventional treatment for my pet

I have scheduled a conventional oncology appointment but have not yet spoken with a conventional oncologist/specialist/veterinarian*

I have not consulted with a conventional oncologist/specialist/veterinarian and do not plan to pursue conventional treatment

I have not consulted with a conventional oncologist/specialist/veterinarian but would be open to at your recommendation*

N/a - wellness*

Does your pet currently have any other medical conditions?*

Please describe your pets current quality of life.*

Great*

Good*

Fair*

Poor

Very poor

What are your goals in consulting with us?*

I am seeking a cure to my pets illness

I am seeking a second opinion on my pets case*

I am seeking a combined approach to treating my pet with conventional and integrative treatments*

I am seeking integrative treatments in lieu of conventional services

I am seeking to supplement my pets care through integrative methods*

I am seeking to supplement my pets care through chiropractic or massage treatments*

I do not know what my goal is in consulting with your practice

What financial investment are you able to make in treating this condition?*

Less than $500

$500 to $1000

$1000 to $5000*

More than $5000*

What changes/treatments are you able to commit to in treating this condition?*

(Check only those that are realistic for both you/your family and your pet)

Dietary change to different brand/types of food*

Making diets at home*

Administering a few oral supplements a few times a day*

Administering many oral supplements many times a day*

Administering injectable treatments a few times a day*

Performing weekly in practice treatments*

Performing in practice treatments a few times a month*

Performing in practice treatments monthly*

None of the above

I am seeking out your services because*

I was referred by a veterinarian/friend/acquaintance

I am educated on and understand the philosophy of a holistic approach to disease*

I utilize holistic modalities for myself and/or my family/pets routinely*

I am looking for anything that may help my pet

I reviewed your website and found specific information/services I am looking for*

This is a last resort effort to help my pet

I am only interested in holistic therapies and unwilling to consider conventional treatment options for my pet

I am not within driving distance, but I have a veterinarian who can perform recommended treatments locally

None of the above

Do you have pet insurance? If so, does it cover holistic therapies?*

Veterinarian or Person that made the referral*

What type of holistic modalities do you utilize?*

What type of holistic modalities do you utilize?*

Comments

Consent*

I have read and understand

- We are not a traditional veterinary practice. The intake protocol required forms, and comprehensive scheduling process will differ from what you are used to with other veterinary practices, including requiring a deposit at the time of scheduling.
- We do not offer routine oncology or exotic services. If you are looking for chemotherapy, surgery, radiation therapy, or a primary veterinarian, please refer to the "Trusted Colleagues" section located under the "Resources" tab on our website to find the appropriate specialist for your pet.
- Integrative medicine is not a quick fix and requires a significant amount of time, energy, and finances to be most effective. Natural therapies take longer and build on one another; therefore, many patients are utilizing multiple therapies at one time.
- We are not miracle workers, and last-ditch efforts are not successful in our hands. Putting together a comprehensive integrative protocol, which will often take weeks to months to implement, and be utilized over the totality of your pet’s life is what we specialize in.
- We are not the best fit for every client or every pet and want all of you to get exactly what you are looking for! Please refer to the "Trusted Colleagues" section located under the "Resources" tab on our website to find other trusted colleagues if any of the above statements are not aligned with your goals.
-By signing this form, you acknowledge and accept any policies mentioned above.

Signature*

Comments

This field is for validation purposes and should be left unchanged.

33 Newman Springs Rd,
Suite #2 Tinton Falls, NJ 07724
732-268-8553
[email protected]

Work Hours

M : 9:00am – 2:00pm (Office Staff Only)
T : 9:00am - 7:00pm
W: 9:00am - 7:00pm
Th: 9:00am – 5:00pm
Fri: 9:00am – 5:00pm
Sat & Sun: Closed

*Please note our Holiday hours may differ. Please check our social media for more information around holidays!*

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