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 J Epstein 9 East 71st Street New York NY 10021 Telephone: ir Ming by meat aro mem the armee you are ping in Ma main* box anti AN OA baker. Maxiament Vas Ama Card. Exp Date Signature Sig Code Date Account 8/31/2016 11394 Remittance IMPORTANT - PLEASE DETACH UPPER PORTION AND RETURN NTH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 7/28/2016 Previous Balance 2,880.00 7/28/2016 Comp. W. Etch 1 Surface 425.00 3,305.00 7/28/2016 Comp. W. Etch 1 Surface 425.00 3,730.00 7/28/2016 Comp. W. Etch 1 Surface 425.00 4,155.00 7/28/2016 Comp. W. Etch 1 Surface 425.00 4,580.00 7/28/2016 Ortho treatment adult 7,500.00 12,080.00 7/28/2016 Cement Crown 0.00 12,080.00 8/11/2016 AMERICAN EXPRESS 2,880.00 9,200.00 Account Total 9,200.00 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 ate. Current 30 Days 60 Days 90 Days 120+ Days 9,200.00 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 EFTA00316284