Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Mr. Jeff Epstein 9 East 718t Street New York NY 10021 HISTORICAL STATEMENT 12/1/2014 to 3/3/2015 Telephone: Date Account 3/2/2016 9648 RornIttenai ISPOOTANT Pia* OETACH UPPER Name NC RETURN WITH YOUR M YETTAYOE TO Pain CREW TO PROPER ACCOutir Date I Patient Description Charges Credits Balance 8/20/2014 Previous Balance 0.00 12/17/2014 Amalgam 2 Surface Perm. 350.00 350.00 12/17/2014 Recall Oral Exam 40.00 390.00 12/17/2014 Adult Scale & Prophy 180.00 570.00 12./17/2014 Bite Wings 4 Films 65.00 635.00 1/8/2015 Panoramic Film 0,00 635.00 1/8/2015 Ortho treatment adult 7,500.00 8,135.00 1/30/2015 AMERICAN EXPRESS 635.00 7,500.00 2/9/2015 1 Periapical X Ray 25.00 7.525.00 Account Total 7,626.00 Patient Charges 8,160.00 Patient Payments 636.00- Patient Credits 0,00 Patient Debits 0.00 Current We accept credit cards You may comply top part of this statement, or call the office mail. 30 Days 60 Days 90 Days 26.00 7,600.00 120* Days 0.00 0.00 0.00 MOM* J. Magnate 0 D.S. AMn Groyne D.D.S. 7 West Slat Street 7th Flow Mew Yak NY 10019 EFTA01196764