EFTA00619776.pdf

MAR-22-2002 09:58 FROM:OR.MAGNANI 2123979008 TO:16.467067223 r• l'1 HISTORICAL STATEMENT 1/1/2013 to 3/21/2013 Thomas J. Magnani D.D. Telephone Mr. Jeff Epstein 301 East 66th Street Dole Account Apt 1OF 3/21/2013 9648 New York NY 10066 Date Patient '1' Description Charges Credits Balance 1/4/2013 Recall ral Exam 1/4/2013 40.00 40.00 Adult 50ale & Prophy 1/4/2013 180.00 220.00 Add Per apical X Rays i t 10.00 1/9/2013 Amalgti 2 Surface Perm. 230.00 1/29/2013 375.00 605.00 Porcelall W. Gold Crown 900.00 1/30/2013 Case et mplete 1,505.00 0.00 1,505.00 4 T. 'Is .:i i. 1 t i N r 5 Account Total 1,605.00 ., i Patient Charges 1,506.00 Patient Payments 0.00 2; I Patient Credits 0.00 Patient Debits 0.00 s Current 30 Days 60 Days 90 Days 120+ Days Thomas J. Megnani D.D.S AMn G D.D.S. 7 West Slat Strom 7ttbor New York NY 10019 (212) 688-1090 EFTA00619776