STATEMENT

STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Telephone: L 'Peri by ere ninnt man lie mount yw we pa In IN /eminence box and Iii out taw Msitercard Mu Pax Card* Ey Ca Scram till Code Date Account 11/27/2013 9648 RS* IMPORTANT. PLEASE DETACH UPPER PORTION MID RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date 10/31/2013 Patient Description Current Charges I Credits Previous Balance 0 a£'.'u 01446 Balance —I 220.00 Account Total 220.00 You have probably overlooked this statement. Your remittance would be appreciated. We accept credit cards You may complete and return the top part of this statement, or call the office al 30 Days 60 Days 90 Days 0.00 0.00 220.00 0.00 120+ Days 0.00 Thomas J. Magnani D.D.S. Alvin Grayson D D S 7 West 51St Street 7th Floor New York NY 10019 EFTA00313297