EFTA02686002.pdf

STATEMENT Thomas J. Magnani D.D.S. Telephone: (212) 688-1090 Alvin Grayson D.D.S. 7 West 51st Street .1 pay ng er r <red,t tare enter the amount yto aro WHM In Re mouttance bet, as ['Wow 7th Floor Mastercard Vtsa — Ames New York NY 10019 CAM S Ep Data Statute S g Code Mr. Jeff Epstein Date Account 301 East 66th Street 1/5/2011 9648 Apt 10F Remittance New York NY 10065 IMPORTANT . PLEASE CETACH UPPER PORTION MP RE1URN WITH YOUR REMITTANCE TO INSURE CREPT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/24/2010 Previous Balance 0.00 11/22/2010 FMS with Bite wings 175.00 175.00 11/22/2010 Amalgam 1 Surface Perm. 325.00 500.00 11/22/2010 Amalgam 3 Surface Perm. 375.00 875.00 12/13/2010 Comp. W. Etch 1 Surface 275.00 1,150.00 12/13/2010 Comp. W. Etch 1 Surface 275.00 1,425.00 12/14/2010 Comprehensive Oral eval 50.00 1,475.00 12/14/2010 Adult Scale & Prophy 160.00 1,635.00 12/17/2010 MASTER CARD 1,425.00 210.00 12/20 ( ` 12/20!2010' 2015-113\ Porcelain W. Gold Crown 1,850.00 2,060.00 Account Total 2,060.00 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 I 60 Days 90 Days 120+ Days 2,060.00 0.00 0.00 J 0.00 0.00 Thomas J. Magnam D. D.S. Alvin Grayson D 0 S 7 West 51st Street 7th Floor Now York NY 10019 EFTA_R1_02010742 EFTA02686002