Secure Online Payment
Pay Your Bill
Make a payment through our secure portal. Have your statement nearby so you can enter the chart number for your account.
Open Payment PortalWhere to find your chart number
Look for the box labeled Chart No. at the top right of your statement.
STATEMENT OF ACCOUNT
Sansom Dental
2505 East 3300 South #101
Salt Lake City, UT 84109
(801) 467-6381
GUARANTOR NAME AND MAILING ADDRESS
Patient Name
123 Family Lane
Salt Lake City, UT 84109
CHART NO.
PAGE NO.
M00020
1
BILLING DATE
05/29/2026
Chart number
PLEASE RETAIN THIS PORTION OF THE STATEMENT FOR YOUR RECORDS
DATE
DESCRIPTION
PATIENT'S NAME
CHARGES
CREDITS
04/29/2026
Balance Forward
0.00
PRIOR BALANCE
CURRENT CREDITS
CURRENT CHARGES
NEW BALANCE
0.00
0.00
0.00
0.00
What you'll need
Your statement
Use the chart number highlighted here so the payment is applied to the right account.
Payment details
Enter your payment amount in the secure portal.
Need help?
If you cannot find your chart number, call or text our office.