HISTORICAL STATEMENT

HISTORICAL STATEMENT 12/1/2014 to 3/3/2015 Thomas J. Ma Alvin Graysonle 7 West 51at Street 7th Floor New York NY 10019 Mr. Jeff Epstein 9 East 71st Street New York NY 10021 Telephone: (212) 688.1090 Date McCunt 1 3/3/2016 9648 Remittent. wiPOOTAY, Ptaie Ont. UPPER PORTION NC ROW WITH YOUR 10 miTTATOE TO Ian t.E.O. TO PROPER Ptectwr Date Patient Description Charges Credits Balance 6/20/2014 Previous Balance 0.00 12/17/2014 Amalgam 2 Surface Penn. 350.00 350.00 12/17/2014 Recall Oral Exam 40.00 390.00 12/17/2014 Adult Soak, & Prophy 180.00 570.00 12/17/2014 Bite Wings 4 Films 65.00 635.00 1/8/2015 Panoramic Film 0,00 635.00 1/8/2015 Ortho treatment adult 7,500.00 8,135.00 1/30/2015 AMERICAN EXPRESS 635.00 7,500.00 2/9/2015 1 Periapical X Ray 25.00 7.525.00 Account Total 7,626.00 Patient Charges 8,160.00 Patent Payments 636.00- Patient Credits 0.00 Patient Debits 0.00 We accept credit cards You may complete and Mum the top part of this statement, or call the office at 212488-1090. Current 30 Days 60 Days 26.00 7,600.00 0.00 90 Days 120+ Days 0.00 0.00 Them* J. iilleonanl M. Min Groton M. 7 West 51st Street 7th 1:100, New York NY 10019 (212) 689-1090 EFTA00589753