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 9 East 71st Street New York NY 10021 Telephone: If or" by aede card. at Ihe amount you are Ring N de manna box and Mad below Minlitard Wa AMU Cards Exp DIN Signature Sig CNN Date Account 6/29/2016 3114 Remittance IMPORTANT • PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREPT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 5/26/2016 6/7/2016 6/7/2016 6/7/2016 Jeff Jeff Jeff Previous Balance Recall Oral Exam Adult Scale & Prophy Fluorid 40.00 180.00 12.00 0.00 40.00 220.00 232.00 Account Total 232.00 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 232.00 0.00 0.00 0.00 0.00 Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 EFTA00316253