HISTORICAL STATEMENT

HISTORICAL STATEMENT 12/1/2014 to 3/3/2015 Thomas J. Magnanl 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: Date Account 3/2/2016 9648 serntnence NEPOOTANT PLEASE OETACII UPPER PORTION NC RETURN WITH YOUR M IIITYNCE TO INSURE MOO TO PROPER ACCOutir Date I Patient 8/20/2014 12/17/2014 12/17/2014 12/17/2014 12./17/2014 1/8/2015 1/8/2015 1/30/2015 2/9/2015 Current Description Charges Credits Balance Previous Balance Amalgam 2 Surface Perm. Recall Oral Exam Adult Scale & Prophy Bite wings 4 Films Panoramic Film Ortho treatment adult AMERICAN EXPRESS 1 Periapical X Ray 350.00 40.00 180.00 65.00 0,00 7,500.00 635.00 25.00 0.00 350.00 390.00 570.00 635.00 635.00 8,135.00 7,500.00 7,525.00 Account Total 7,626.00 Patient Charges 8,160.00 Patient Payments 636.00- Patient Credits 0.00 Patient Debits 0.00 We accept credit cards You may comply top part of this statement, or call the office sail. 30 Days 60 Days 90 Days 26.00 7,600.00 120* Days 0.00 0.00 0.00 moon J. JAsonsnl 0 D.S. AMA Orsylon D.D.S. 7 Weal 51st Stress 7th Floor New York NY 10019 EFTA01196766