EFTA01118666.pdf

STATEMENT Thomas J. Magnani D.D.S. Telephone: (212) 688-1090 Alvin Grayson D.D.S. 7 West 51st Street I payer/ by credit cant elver Um, amount you we payog n the unnetenco box end out tete 7th Floor MaslercatO Visa Nnox New York NY 10019 Cues Exp Ose Scnaluro Sg Code Irina Stremyakova 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 Previous Balance 0.00 4/18/2012 Irina 1 Periapical X Ray 25.00 25.00 4/18/2012 IrMa Amalgam 2 Surface Perm. 375.00 400.00 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