EFTA Document EFTA01733888

HISTORICAL STATEMENT 1/1/2016 to 10/6/2016 Thomas J. Magnani D.D.S. Alvin r .S. Mr. Jeff Epstein 9 East 71st Street New York NV 10021 Telephone: Dale Account 10/6/2016 8150 Remittance IMPORTANT • PLEA-SE OETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 10/20/2015 Previous Balance 0.00 2/25/2016 Office Visit 0.00 0.00 9/14/2016 Post 1,400.00 1,400.00 9/14/2016 Porcelain W. Gold Crown 2,200.00 3,600.00 10/6/2016 Night Guard 325.00 3,925.00 10/6/2016 Comp. W. Etch 1 Surface 375.00 4,300.00 Account Total 4,300.00 Patient Charges 4,300.00 Patient Payments 0.00 Patient Credits 0.00 Patient Debits 0.00 We accept credit cards You may complete top part of this statement, or call the office alai. Current 30 Days 60 Days 90 Days 120+ Days 4,300.00 0.00 0.00 0.00 0.00 Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. EFTA_R1_00010466 EFTA01733888 • Re•dentist tember 14 2016 at 4:46 PM Hi belle. Just wanted to let you know some more bills will be coming from DR Magnani. It's the same tooth that JE approved, it's just been taking a while to finished because I had to have a new filling and crown. Xox EFTA_R1_00010467 EFTA01733889