STATEMENT

STATEMENT Thomas J. Magnani Mr. Jeff Epstein M. Box 806 New York NY 10150 Telephone: II pang by =di cad, raw dr amount you an pang In the rtffiltlita bac aid ■ out bar. Idubraud Anon Card* En Oro Span Sc Con Date Account 5/9/2013 10345 Remittance IMPORTANT PLEASE DETACH UPPER PORTION MO RETURN YATN YOUR REMITTANCE 10 INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 3/28/2013 4/4/2013 4/17/2013 Julia Julia Previous Balance Laser Bleaching VISA 750.00 332.00 332.00 1,082.00 750.00 Account Total 750.00 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 a Current 750.00 30 Days r 60 Days 90 Days 0.00 120+ Days 0.00 0.00 0.00 Thomas J. Magnani A/yin Grayson EFTA00313133