STATEMENT

STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. Mr. Jeff Epstein 301 East 66th Street Apt 1OF New York NY 10; rn kf Telephone: I paying by credit cant enter Me amount you are barna in IM rempitance box and hi out below Masten:ant visa Amax Card N Gip Des Soanatunt So Cods Date Account 12/14/2010 9648 Remittance PAPORTANT PLEASE DETACH UPPER PORTION AND RETURN WITH YOLK REIETTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/24/2010 Previous Balance 0.00 11/22/2010 FMS with Bite wings 175.00 175.00 11/22/2010 Amalgam 1 Surface Perm. 325.00 500.00 11/22/2010 Amalgam 3 Surface Perm. 375.00 875.00 12/13/2010 Comp. W. Etch 1 Surface 275.00 1,150.00 12/13/2010 Comp. W. Etch 1 Surface 275.00 1,425.00 Account Total 1,425.00 We accept credit cards! You may complete and return the top part of this statement, or call the office at 212488-1090. Current 30 Days 60 Days 90 Days 120+ Days 1,425.00 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 Now York NY 10019 EFTA00599985 STATEMENT Thomas J. Magnani D.D.S. Telephone: Alvin Grayson D.D.S. " PaY., 3 t cteltl crd enter Ow amovg you w paling in an re'n.r2^c," cov end Ls out !claw Amex Cord 0 Up Dail Sloshes Sc Don Mr. Jeff Epstein 457 Madison Avenue 4th Floor New York NY 10022 Date Account 11/24/2010 9649 Remittance IMPORTAIC • PLEASE DETACH UPPER PORTION AND RETURN WITH YOLK REmITTANDE TO INSURE CRC-DR TO PROPER ACCOLAIT Date Patient Description Charges Credits Balance Previous Balance 0.00 11/24/2010 Comprehensive Oral oval 50.00 50.00 11/24/2010 Adult Scale & Prophy 160.00 210.00 Account Total 210.00 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 210.00 0.00 0.00 0.00 0.00 Thomas J. Mao na ro D. D S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor Now York NY 10019 EFTA00599986 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 457 Madison Avenue 4th Floor New York NY 10022 Telephone: r pay% by Clodol Cu. antes the amount yOu are payong n PH reinba 0 Wu and Id out Wow Mastrusal Vni Amax Caro . EN, Oar Srature SO Cato Date Account 11/24/2010 3114 Remittance IMPORTANT. PLEASE CETACH UPPER PORTION AND RETURN WITH YOUR REfrATTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 10/27/2010 Previous Balance 1,900.00 10/27/2010 Jeff MASTER CARD 1,900.00 0.00 10/27/2010 Jeff Ins Form submitted - Aetna 11/19/2010 Jeff Recall Oral Exam 35.00 35.00 11/19/2010 Jeff Adult Scale & Prophy 160.00 195.00 11/19/2010 Jeff Ins Form submitted - Aetna Account Total 195.00 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 212-688-1090. Current 30 Days 60 Days 90 Days 120+ Days 195.00 0.00 0.00 0.00 0.00 Thomas J. Magnani 0.D S Alvin Grayson D.D.S 7 West 51st Street 7th Floor New York NY 10019 EFTA00599987