STATEMENT

STATEMENT Thomas J. Ma . Telephone: Alvin Grayson IM MO bY COON cad. Oftlit the Sniourd you we ming n Ire in CS OCCC ells Out below Mastercard Asa Amex Card• E,p OM. WAIN Sig COOS /Mr. Jeff Epstein / 301 East 66th Street I Apt 3 1OF ' New York NY 10065 Date 5/9/2013 Account 9293 Remittance impoR, ;4,4 MINN OfThtli UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT 77:late Patient Description Charges Credits Balance 3/28/2013 Previous Balance 0.00 4/2/2013 Svetleana Recall Oral Exam 40.00 40.00 4/2/2013 Svetleana Adult Scale & Prophy 180.00 220.00 4/2/2013 Svetleana Bleach Touch-Up Kit 65.00 285.00 Account Total 285.00 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 285.00 0.00 90 Days 120+ Days 0.00 0.00 0.00 Thomas J. Magnani Alvin Grayson M. EFTA00313134