STATEMENT

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 9 East 71st Street New York NY 10021 Telephone payrg I y aecl4 card. lute tlM arnouni you .it plying el fa reatittince boa and fil col Mow Messcate1 Vas Amex Cues Exp Des Donau.* Sp Cede Date Recount 3/28/2015 10918 Remittance NOORTANT • PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMMNCE TO INSURE CREW TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 2/26/2015 Previous Balance 0.00 2/26/2015 Simon Comprehensive Oral eval 60.00 60.00 2/26/2015 Simon Adult Scale & Prophy 180.00 240.00 2/26/2015 Simon Fluorid 12.00 252.00 2/26/2015 Simon FMS with Bite wings 175.00 427.00 3/2/2015 Simon Adult Scale & Prophy 180.00 607.00 3/5/2015 Simon Amalgam 2 Surface Perm. 450.00 1,057.00 3/5/2015 Simon Amalgam 3 Surface Perm. 475.00 1,532.00 3/5/2015 Simon Amalgam 2 Surface Perm. 450.00 1,982.00 3/9/2015 Simon Amalgam 2 Surface Perm. 425.00 2,407.00 3/9/2015 Simon Amalgam 2 Surface Perm. 425.00 2,832.00 3/17/2015 Simon Amalgam 2 Surface Perm. 475.00 3,307.00 3/17/2015 Simon Amalgam 3 Surface Perm. 475.00 3,782.00 3/19/2015 Simon Amalgam 2 Surface Perm. 425.00 4,207.00 Account Total 4,207.00 if payment has been sent, please disregard this statement - Thank You. We accept credit cards! You may complete and return the to part of this statement, or call the office at Current 30 Days 60 Days 4,207.00 0.00 0.00 90 Days 0.00 120+ Days 0.00 Thomas J. Magnani AMn Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 EFTA00670850