STATEMENT

STATEMENT Thomas J. Ma nani Alvin Grayson Jeff Epstein 301 East 66th Street Apt # 10 f New York NY 10065 Telephone: barns, by tsdl tral Onber the amount you an payffig ffi the tanffiewca sax ern M Out below liattaffiard Vna Arnow Card • Effi Dr* Sinaltee Sg Cade Date Account 9/28/2011 3114 Rerniaanee IMPOITANT • PLEASE CerACN UPPER PORTION AND RETURN WITH YOUR ROITTANCE TO INSURE CREDO TO PRCPER ACCOUNT r Date Patient Description Charges Credits Balance 8/31/2011 8/31/2011 9/12/2011 9/12/2011 Jeff Jeff Jeff Previous Balance MASTER CARD Recall Oral Exam Adult Scale & Prophy 40.00 180.00 197.00 197.00 0.00 40.00 220.00 Account Total 220.00 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 90 Days 120+ Days 220.00 0.00 0.00 0.00 0.00 Thomas J. Magnani=. Alvin Grayson-, EFTA00312737