Family Information ( For All Patients) - Please Use Full Legal Name
If parents are divorced/separated/not married - please fill out this section
Children Information (Please Use Full Legal Name)
Notice to Consumers
Medical Doctors are licensed and regulated by the Medical Board of Utah 801-530-6628
Payment in full is due within 60 days from the date of service. If payment in full is not made as required, then in addition to all other amounts that may be due, I agree to pay a collection fee up to 40% of the principal amount as provided by §12-1-11 of the Utah Code Annotated, and further agree to pay all other costs of collection (whether incurred by Comfort Care Pediatrics or its or its assigns) including but not limited to court costs, reasonable attorney fees, and interest (both pre and post judgment). Any interest due hereunder shall be calculated at a rate equal to 18% per annum and may, as determined by Comfort Care Pediatrics or its assigns: (a) accrue on some or all amounts due and (b) compou8nd as frequently as daily –meaning that accruing interest may be added to the balance owing as frequently as daily such that it shall thereafter constitute part of the amount upon which interest accrues during the next accrual period. The terms of this paragraph shall apply to all amount(s) incurred by me or by any individual for whom I have legal responsibility whether such amount(s) are incurred today or after today.
I hereby consent to being contacted by telephone at any telephone number (including, but not limited to, wireless/cellular phone numbers) provided by me or anyone associated with me or acting on my behalf to Comfort Care Pediatrics or anyone acting on its behalf. I understand and agree that such calls may be initiated by Comfort Care Pediatrics or any of its affiliates, agents, contractors, or assigns, including but not limited to companies and or third-party collection agency(ies), and that the methods of contact may include using pre-recorded/artificial voice messages and/or the use of an automated dialing service and/or the use of text messages – some or all of which may result in data charges. I also consent to receiving e-mails at any email address provided by me or anyone associated with me or acting on my behalf.