Name
(Required)
First
Last
I am an existing client*
(Required)
Yes
No
Are you able to come in person to the practice for a consultation?*
(Required)
Yes
No
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 prescribed or dispense medications. Following initial consultation, telemedicine appointments are readily available to clients, however physical exams are required annually. For clients unable to travel to the office for initial consultation, please visit our resources tab where you can find our trusted colleagues that may be more local to you.
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Your Pet's Name*
(Required)
Pet's Species
(Required)
Canine
Feline
Exotic
Pet's Sex
(Required)
Male
Male – Neutered
Female
Female – Spayed
Pet's Sex
(Required)
Male
Male – Neutered
Female
Female – Spayed
Unknown (exotic only)
How did you hear about us?
Veterinarian
Word of Mouth
Practice Website
Internet Search
Facebook
Instagram
Other
Pet's date of birth or age
(Required)
MM slash DD slash YYYY
Have you been referred to see a specific doctor?
Please Select
Yes
No
While Dr. Marino facilitates the majority of our case load at the practice, Dr. Pope does see new patients on a limited basis.
I am requesting an appointment for the following:*
Integrative Oncology/Integrative Medicine/Wellness
Acupuncture Only
Unsure
You may select multiple appointment options
What are your goals in consulting with us?
(Required)
Today's Date
MM slash DD slash YYYY
Comments:
Consent
I agree to the privacy policy.
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 and a required credit card saved on file 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.
A staff member will reach out via email with next steps for an appointment within 3 business days of submitting this request. Please check your spam and promotions folder. Thank you!
Signature
(Required)
CAPTCHA