STATEMENT

STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Jeff Epstein P.O. Box 806 New York NY 10150 add/WI-1 Telephone: rt prwrp by credriald. onler the coon you we miner UM tiordlince b snit fill 04.4 belOvi Malietaird VIM /hex Cad Oeis Silenalum Sp Cos Dab Account 4/30/2014 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 4/23/2014 4/25/2014 4/25/2014 4/29/2014 4/29/2014■ 4/29/2014 Jeff Jeff Jeff Previous Balance 1 Periapical X Ray surgical extraction Gum Graft 25.00 1,200.00 1,200.00 180.00 40.00 175.00 0.00 25.00 1,225.00 2,425.00 2,605.00 2,645.00 2,820.00 Account Total 2,820.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cardsl You may complete and return the top part of this statement, or call the office a . Current 30 Days 1 60 Days 90 Days 120+ Days 2,820.00 0.00 0.00 0.00 0.00 Thomas J. Magnani D.D.S. Alen Grayson O.D.S. 7 West Stet Street 7th Flow New York NY 10019 EFTA00311292