Do not include Protected Health Information (PHI) in this form. If you are an existing patient or client, please use your secure portal for all communication. By submitting this form, I acknowledge and agree that Bella Medical Associates may contact me via email, phone, or mail, and that the information provided will be used solely to respond to my inquiry and may be stored in accordance with the Privacy Policy and Terms & Conditions. Submission of this form does not establish a patient-provider, client-service relationship or contractual agreement.