Thomas J. Ma

Thomas J. Ma Alvin Grayson 7 West 61st SWee 7th Floor Now York NY 10019 Mr. Jeff Epstein 9 East 71st Street New York NY 10021 HISTORICAL STATEMENT 12/1/2014 to 3/3/2015 Telephone: vete Account 3/3/2015 10345 Remtesno. — PSPORTMT - PLEASE DETACH UPPER PORTION AND RETURN WITH TWA REnITTAm '3 TO mutt CREW 70 PROPER ACCOUHt Date Patient Description Charges Credits Balance 7/18/2014 Previous Balance 0.00 12/23/2014 Julia Recall Oral Exam 40.00 40.00 12/23/2014 Julia Adult Scale 8 Prophy 180.00 220.00 12/23/2014 Julia Fluorid 24.00 244,00 12/23/2014 Julia Bleach Touch-Up Kit 65.00 309.00 2/25/2015 Julia Comp. Etch 4 or more Sur 475.00 784.00 2/25/2015 Julia Comp. W. Etch 2 Surface 475.00 1,259.00 Account Total 1,269.00 Patient Charges 1,259.00 Patient Payments 0.00 Patient Credits 0.00 Patient Debits 0.00 We accept credit cards You may complete p part of this statement, or call the office at Current 950.00 DeY3 0.00 60 Days 90 Days 309.00 0.00 120+ Days 0.00 Thomas J MagnerilIM Alv91 Gityson 7 Witt 51st Simi 7th near N8w York NY 10019 EFTA00654206