STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 New York NY 10019 Telephone: PrArt9 by aeon cant enter NM amount you mre paving A he •Oul below Mysiercad Vise krou Cads E xp OM* Sinaboo Si9 CNN ermlwAt L'OX and Dabs Account 4/19/2012 IMPORTANT • Pt EASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT 70 PROPER ACCOUNT Remittance 1 Date Patient Description Charges Credits Balance Previous Balance 0.00 4/18/2012 1 Periapical X Ray 25.00 25.00 4/18/2012 Amalgam 2 Surface Perm. 375.00 400.00 Account Total 400.00 We accept credit cards You may complete and return the top part of this statement, or call the office at Current 30 Days 60 Days 90 Days 120+ Days 400.00 0.00 0.00 0.00 0.00 Thomas J Magram D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 EFTA_R1_02059707 EFTA02698720