STATEMENT

STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Jeff Epstein 9 East 71st Street New York NY 10021 Telephone: (212) 688-1090 I pry,.; by creed Geed enle, the irrounl rai va c-reriC mw. sni • MA talow. Vlia Ar Ca Cans s Ero Dale Strout sccxw Date Avows 11/26/2014 I: 3114 Remittance IMPORTANT - PLEASE DETACH UPPER PORTON NC RETURN Van YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 10/30/2014 11/21/2014 11/21/2014 Jeff Jeff Previous Balance Recall Oral Exam Adult Scale & Prophy %II petty. 40.00 180.00 kimip A et&kit ntaar.- loiticipi{ 0.00 40.00 220.00 Account Total 220.00 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. Current 30 Days 60 Days 90 Days 120+ Days 220.00 0.00 0.00 0.00 0.00 Thomas J. laegnanl D.D.S. AMn Grayson D.O.S. 7 West 5151 Street 7th Floor New York NY 10019 (212) 686-1090 EFTA01122953 STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Jeff Epstein 9 East 71st Street New York NY 10021 Telephone: (212) 688-1090 I Wog by cryailast. OM. MO anoint yen are poling FM teyeaance box aloof bekw. Witilawd May Cud • Exp Stenin Dada Date Account 6/3/2015 3114 Remilanca SIPORTANT • PUG= DETACH UPPER PORTION NC RIMJRN NTH MIR REACTANCE TO INSURE CREPT TO PROPER ACCEMMT Date Patient Description Charges Credits Balance 4/30/2015 5/19/2015 5/19/2015 Jeff Jeff Previous Recall Oral Exam Adult Scale & 3 Balance Prophy poc_96-.___ , 40.00 180.00 ficyv 0.00 40.00 220.00 Account Total 220.00 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. Current 30 Days 60 Days 90 Days 120+ Days 220.00 0.00 0.00 0.00 0.00 Thomas J. Magnani D.D.S. Akin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 (212)688.1090 EFTA01122954 Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 61st Street 7th Floor STATEMENT Telephone: (212) 688-1090 ■Ooy'N by ma cat. MW INT Emma ma as WOW MM n,Ms,c. Doi EEE awl Wow. New York NY 10019 Malward NY Mw Cad Ea OW awakes St Cosi Jeff Epstein Date Account 9 East 71st Street 9/30/2015 3114 New York NY 10021 Remnant* WPORTMa • EtFASE OETACN UPPER PORTION NU RETURN WIN VOLE REIETTANCE TO 1141104 CROTTY 10 PROPER a:COUNT Date Patient Description Charges Credits Balance 8/26/2015 8/28/2015 8/28/2015 Jeff Jeff Previous Balance Recall Oral Exam Adult Scale & Prophy 40.00 180.00 0.00 40.00 220.00 Account Total 220.00 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. Current 30 Days 60 Days 90 Days 120+ Days 220.00 0.00 0.00 0.00 0.00 Thomas J. Magner)] D.O.S. Alvin Grayson D.O.S. 7 West 51st Street 7th Fbor New York NY 10019 (212)688-1090 EFTA01122955 STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.O.S. 7 West 51st Street 7th Floor New York NY 10019 Jeff Epstein 9 East 71st Street New York NY 10021 Telephone: (212) 688-1090 pan by nal tent ocae Na aTa.nl man:WPM in Ra nanOnce boXrd NW Gana Mokami Von Amu Cad Ell DS &analuro SO Cale Date Account 10/29/2015 3114 Remittance IMPORTANT • PLEASE DETACH UPPER POROON MO RETURN Will YOUR RFJaITANCE TO INSURE OREM TO PROPER ACCOUtff Date Patient Description Charges Credits Balance 9/30/2015 9/30/2015 9/30/2015 10/20/2015 Jeff Jeff Jeff Previous Balance endosteal implant Cone beam CT image half jaw AMERICAN EXPRESS 3,000.00 525.00 220.00 220.00 3,220.00 3,745.00 3,525.00 Account Total 3,525.00 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. Current 30 Days 60 Days 90 Days 120+ Days 3,525.00 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) 688-1690 EFTA01122956 HISTORICAL STATEMENT 1/5/2016 to 2/24/2016 Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 61st Street 7th Floor New York NY 10019 Jeff Epstein 9 East 71st Street New York NY 10021 Telephone: (212) 688-1090 Date Account 2/24/2016 3114 Romeance NPORTANT PLEASE DETACH UPPER PORTION NC REM/MI/4Th YOUR RENTTAKE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/25/2015 Previous Balance 0.00 1/5/2016 Jeff Abut Sup Porc/Gold Crown 2,300.00 2,300.00 1/5/2016 Jeff Abutment Placement 1,400.00 3,700.00 2/3/2016 Jeff Adult Scale & Prophy 180.00 3,880.00 2/3/2016 Jeff Recall Oral Exam 40.00 3,920.00 2/24/2016 Jeff AMERICAN EXPRESS 3,920.00 0.00 Account Total 0.00 Patient Charges 3,920.00 Patient Payments 3,920.00- Patient Credits 0.00 Patient Debits 0.00 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 0.00 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 EFTA01122957 STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 61st Street 7th Floor New York NY 10019 Jeff Epstein 9 East 71st Street New York NY 10021 Telephone: (212) 688-1090 I paying by veal cant *Met tha Mount yo., are p>/n0 U M lemlanCe 00A *?d el out beton. MastcaN Vloa Mut Gird • ESP Oso 5Grusliefi Sig COZO Oate Account 3/30/2016 3114 Remit:Inca rUPORTAN1 . PLEASE DETACH UPPER PORTION N40 RLT LAIN WIN YOUR REIATTNCE TO INSURE CREDIT' TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 3/2/2016 Previous Balance 0.00 3/7/2016 Jeff Temporary Cement 375.00 375.00 3/30/2016 Jeff 1 Surface Comp. Posterior 425.00 800.00 rf b6 l6 ,- Account Total 800.00 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. Current 30 Days 60 Days 90 Days 120« Days 800.00 0.00 0.00 0.00 0.00 Thomas J. Magnanl D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New Voik NY 10019 (212)688-1010 EFTA01122958