STATEMENT

STATEMENT Thomas J. Magnani D.D.S. Telephone: (212) 688-1090 Alvin Grayson D.D.S. 7 West 51st Street II paying by area aft mat M emowe you we fleYieq n to remittance box and 7th Floor NI eel beket NatWest Vali Amex New York NY 10019 Cade Exp Oete Suitable Sig Code Mr. Jeff Epstein Date Account 301 East 66th Street 10/27/2011 9648 Apt 10F Remittance New York NY 10065 imPORTNe r - PIPASE DETACH UPPER PORTION NC RETURN WITH YOUR REMITTANCE TO INSURE CREDI T t0 PROPER ACCOUNT Date Patient Description Charges Credits Balance 9/28/2011 10/25/2011 10/25/2011 10/25/2011 10/26/2011 Current Previous Balance 0.00 Recall Oral Exam 40.00 40.00 Adult Scale & Prophy 180.00 220.00 Fluorid 12.00 232.00 Amalgam 2 Surface Perm. 425.00 657.00 Account Total 667.00 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. 657.00 30 Days 60 Days 90 Days 120+ Days 0.00 0.00 I 0.00 0.00 Thomas J. Magnani D.D.S. Alvin Grayson D.D S. 7 West 51st Street 7th Floor New York NY 10019 (212) 688-1090 EFTA01118593