STATEMENT

STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Mr. Jeff Epstein 9 East 71st Street New York NY 10021 Telephone: if payed by credit ant. enter the motel you are Mire M me torrobara box ad MI out Sleet MaNcecard vaa Amex Card* Ey Da Signalers Sig Code Date Account 7/28/2016 9648 Remittance IMPORTANT- PLEASE DETACH UPPER PORTION AND RETURN PATH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 6/29/2016 7/20/2016 7/20/2016 Previous Balance 1 Periapical X Ray Amalgam 2 Surface Perm. v 0 30.00 375.00 a 0.00 30.00 405.00 Account Total 405.00 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 405.00 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 EFTA00316267