STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Mr. Jeff Epstein 301 East 66th Street Apt 1OF New York NY 10065 1111)-1 IC/\_ Telephone: (212) 688-1090 II paying by credit cant ant too amount you ant ph+n; on IM rempnanco box and hi out tdow Manned Visa Amens Card N &gnaw.* So Con Fip On Date Account 12/14/2010 9648 Remittance IMPORTANT. PLEASE DETACH UPPER PORTION AND RETURN WITH YOLK RES/TRANCE TO iNSVRE CREW TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/24/2010 Previous Balance 0.00 11/22/2010 Renata FMS with Bite wings 175.00 175.00 11/22/2010 Renata Amalgam 1 Surface Perm. 325.00 500.00 11/22/2010 Renata Amalgam 3 Surface Perm. 375.00 875.00 12/13/2010 Renata Comp. W. Etch 1 Surface 275.00 1,150.00 12/13/2010 Renata Comp. W. Etch 1 Surface 275.00 1,425.00 Account Total 1,425.00 We accept credit cards! You may complete and return the top part of this statement, or call the office at 212-688-1090. Current 30 Days 60 Days 90 Days 120+ Days 1,425.00 0.00 0.00 0.00 0.00 Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 EFTA01155767 STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Mr. Jeff Epstein 457 Madison Avenue 4th Floor New York NY 10022 Telephone: (212) 688-1090 pay.-.2 ty veld cad. gofer Ow *mum you an PINK n U ,. *cane. Ma INS ES tot tcow lioNonad Ono Amex Cord• Up Das Donohoe Sop Code Date Account 11/24/2010 9649 Remittance kMPCRTAKr • PLEASE CETACH UPPER PORTION AND RETURN WITH VOLE REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance Previous Balance 0.00 11/24/2010 Gulsyum Comprehensive Oral oval 50.00 50.00 11/24/2010 Gulsyum Adult Scale & Prophy 160.00 210.00 Account Total 210.00 We accept credit cards! You may complete and return the top part of this statement, or call the office at 212-688-1090. Current 30 Days 60 Days 90 Days 120+ Days 210.00 0.00 0.00 0.00 0.00 Thomas J. Magna ril D.D S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor Now York NY 10019 EFTA01155768 STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Mr. Jeff Epstein 457 Madison Avenue 4th Floor New York NY 10022 Telephone: (212) 688-1090 !paying by Crodol este ante, the Amount Mu are papal' Ni the renvItanCe box and NI out tekne Welotrellib Visa bine% card t EN, Date Sanalbre So Cod. Date Account 11/24/2010 3114 Remittance IMPORTANT. PLEASE CETACH UPPER PORTION AND RETURN WITH YOUR RETATTAXCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 10/27/2010 Previous Balance 1,900.00 10/27/2010 Jeff MASTER CARD 1,900.00 0.00 10/27/2010 Jeff Ins Form submitted - Aetna 11/19/2010 Jeff Recall Oral Exam 35.00 35.00 11/19/2010 Jeff Adult Scale & Prophy 160.00 195.00 11/19/2010 Jeff Ins Form submitted - Aetna Account Total 195.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards! You may complete and return the top part of this statement, or call the office at 212-688-1090. Current 30 Days 60 Days 90 Days 120+ Days 195.00 0.00 0.00 0.00 0.00 Thomas J. Magnani 0.D S Alvin Grayson D.D.S 7 West 51st Street 7th Floor New York NY 10019 EFTA01155769