STATEMENT

STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. Mr. Jeff Epstein PO Box 806 New York NY 10150 a, Telephone: par, by amid cmd. PAW the amount you we nom st o,e nuniMmai bra and al as Mom II•Minard *taw CAM a E Ofte Signolan Ey Cow Come 4/30/2014 Account Remittance IMPORTANT - PI.EASE DETACH UPPER PORTION MD RETURN WITH YOUR REMIT/VICE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 3/27/2014 Previous Balance 0.00 3/28/2014 Recall Oral Exam 40.00 40.00 3/28/2014 Adult Scale & Prophy 180.00 220.00 402014 Comp. W. Etch 1 Surface 350.00 570.00 4/2/2014 Comp. W. Etch 1 Surface 350.00 920.00 Account Total 920.00 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 Current 30 Days 60 Days 920.00 0.00 I 0.00 90 Days 120* Days 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 EFTA00311291