Thomas J. Magnani D.D.S.

Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 61st Street 7th Floor STATEMENT Telephone: ■ pare by cret54 cud. *Mr the amount you re N oul below Mastecan1 Mese AMOY wow mar molten WON New York NY 10019 bp Dais Cardo Mr. Jeff Epstein SONS, SO Code Dab Account 9 East 71st Street 1/7/2015 10055 New York NY 10021 Remittance IMPORTANT PEASE DETACH UPPER PORTION ANO RETURN NTH YOUR RESETTNCE TO INSURE CREW TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/26/2014 12/15/2014 12/15/2014 12/18/2014 Sue Sue Sue Previous Balance Recall Oral Exam Adult Scale & Prophy Amalgam 2 Surface Perm. 40.00 180.00 425.00 0.00 40.00 220.00 645.00 If payment We accept has been sent, credit cards! this statement, Days 4 please disregard this statement - Thank You may complete atop or call the office at Account Total You. part of 1 645.00 Current 30 60 Days 90 Days 120+ Days 645.00 0.00 0.00 0.00 0.00 Thomas J. Magnin' D.D.S. Alv:n Grayson D.D.S. 7 West 51st Street 7th Floor New Yolk NY 10019 EFTA00638123