DS9 Document EFTA00283635

TO I- • J.' MAR-22-2002 09:58 FROM:DR.MAGNANI Thomas J. Magnani D.D. Alvin Grayson D.D.S. 7 West 51St Street 7th Floor New York NY 10019 Mr. Jeff Epstein 301 East 66th Street Apt 10F. New York NY 10066 HISTORICAL STATEMENT 1/1/2013 to 3/21/2013 Telephone: gelk Dohs Account 3/21/2013 _ Date Patient iti • Description Charges Credits Balance 1/4/2013 Recall ral Exam 40.00 40.00 1/4/2013 Adult le & Prophy 180.00 220.00 1/4/2013 Add P X Rays i it 10.00 230.00 1/9/2013 • apical Amalgel 2 Surface Perm. 375.00 605.00 1/29/2013 Porcelal W. Gold Crown 900.00 1,505.00 1/30/2013 Case mplete 0.00 1,505.00 Account Total 1,605.00 J i i Patient Charges 1,506.00 i Patient Payments 0.00 I PatWnt Credits 0.00 I Patient Debits 0.00 Current 30 Days 60 Days 90 Days 120+ Days Thomas J. MagnaniCIIIS Aniin . 7 West 51st Se 'mar Nev York NY 10019 EFTA00283635