STATEMENT

STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Irina Stremyakova Telephone: (212) 688-1090 I payer/ by credit cant elver Um, amount you we payog n the unnetenco box end out tete MaslercatO Visa Nnox Cues Exp Ose Scnaluro Sg Code Dale Account 4/19/2012 10097 Remittance IMPORTANT • PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 4/18/2012 4/18/2012 Irina IrMa Previous Balance 1 Periapical X Ray Amalgam 2 Surface Perm. 25.00 375.00 0.00 25.00 400.00 Account Total 400.00 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 400.00 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 New York NY 10019 (212) 688.1090 EFTA01118666