EFTA02716984.pdf

STATEMENT Thomas J. Magnani D.D.S. Telephone: Alvin Grayson D.D.S. 7 West 51st Street N paying by veal can& entry Ho amour; you am OWN/ n aM lormitanca box and ■ ext Wow 7th Floor Motorcar! Va. Amex New York NY 10019 Cade Exp Dvrs Sputum Sig Cade Mr. Jeff Epstein Dale Account 9 East 71st Street 7/1/2015 10055 New York NY 10021 Remittance IMPORTANT • PLEASE DETACH UPPER PORTION MO RETURN 'MTH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 6/3/2015 Previous Balance 0.00 6/16/2015 Adult Scale & Prophy 180.00 180.00 6/16/2015 Recall Oral Exam 40.00 220.00 6/16/2015 Electric toothbrush 160.00 380.00 6/16/2015 Laser Bleaching 750.00 1,130.00 Account Total 1,130.00 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 60 Days 90 Days 120+ Days 1,130.00 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 EFTA_R1_02159129 EFTA02716984