STATEMENT

STATEMENT Thomas J. Magnani D.D.S. Telephone: Alvin Graysen S. New York NY 10019 Mr. Jeff E tein New York NY 10150 (Q,vf?qd ■ paying by Me ANAL MS toe nut* yo1 ara pep Si h roniebinco box am AI out Wow Sand Una Amex Card a EN, Ode Straltre se Cada Date Account 4/30/2014 10055 Remittance IMPORTANT - PLEASE OETACH UPPER PORTION NIP RETURN WITH YOUR RE/ARTNCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 3/27/2014 Previous Balance 0.00 4/21/2014 Sue Recall Oral Exam 40.00 40.00 4/21/2014 Sue Adult Scale & Prophy 180.00 220.00 4/21/2014 Sue Bleaching Trays 650.00 870.00 4/22/2014 Sue 1 Surface Comp. Posterior 275.00 1,145.00 4/22/2014 Sue Comp. W. Etch 3 Surface 375.00 1,520.00 Account Total 1,520.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards You may complete a top part of this statement, or call the office at Current 30 Days 1,520.00 0.00 60 Days 90 Days I 120+ Days 0.00 0.00 Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. New York NY 10019 0.00 EFTA00593328