HISTORICAL STATEMENT

HISTORICAL STATEMENT 1/5/2016 to 2/24/2016 Thomas J. Magnani Alvin Gra son Jeff Epstein Telephone: (212) 688-1090 Date Account 2/24/2016 3114 Remittance IMPORTANT PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/25/2015 Previous Balance 0.00 1/5/2016 Jeff Abut Sup Porc/Gold Crown 2,300.00 2,300.00 1/5/2016 Jeff Abutment Placement 1,400.00 3,700.00 2/3/2016 Jeff Adult Scale & Prophy 180.00 3,880.00 2/3/2016 Jeff Recall Oral Exam 40.00 3,920.00 2/24/2016 Jeff AMERICAN EXPRESS 3,920.00 0.00 Account Total 0.00 Patient Charges 3,920.00 Patient Payments 3,920.00- Patient Credits 0.00 Patient Debits 0.00 We accept credit cards You may complete and return the top part of this statement, or call the office at 212-688-1090. Current 30 Days 60 Days 90 Days 120+ Days 0.00 0.00 0.00 0.00 0.00 Thomas J. Magnani . Alvin Grayson M. 7 West 51st Street 7th Floor New York NY 10019 (212) 688-1090 EFTA00589887