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 P.O. Box 806 New York NY 10150 newt, d iun L It parn try axial cant *ow two @mum rzu in 0xr*0 ix Wolobsool box GM fa au ben Telephone: Mastecat0 vww Cora r Exp Sprain Sp Cads Date 4/30/2014 Account 10055 Remittance IMPORTANT • PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 3/27/2014 4/21/2014 4/21/2014 4/21/2014 4/22/2014 4/22/2014 Sue Sue Sue Sue Sue Previous Balance Recall Oral Exam Adult Scale & Prophy Bleaching Trays 1 Surface Comp. Posterior Comp. W. Etch 3 Surface 40.00 180.00 650.00 275.00 375.00 0.00 40.00 220.00 870.00 1,145.00 1,520.00 Account Total 1,520.00 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 I 120+ Days 1,520.00 0.00 0.00 —h0.00 0.00 Thomas J. Magnani D.O.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 (212) 688-1090 EFTA_R1_00360643 EFTA01919018