EFTA01122953.pdf

STATEMENT Thomas J. Magnani D.D.S. Telephone: (212) 688-1090 Alvin Grayson D.D.S. 7 West 51st Street I pry,.; by creed Geed enle, the irrounl rai va c-reriC mw. sni • MA talow. 7th Floor Vlia Ar Ca New York NY 10019 Cans s Ero Dale Strout sccxw Jeff Epstein I: Date Avows 9 East 71st Street 11/26/2014 3114 New York NY 10021 Remittance IMPORTANT - PLEASE DETACH UPPER PORTON NC RETURN Van YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 10/30/2014 Previous Balance 0.00 11/21/2014 Jeff Recall Oral Exam 40.00 40.00 11/21/2014 Jeff Adult Scale & Prophy 180.00 220.00 %I I kimip ntaar.- petty. loiticipi{ A et&kit Account Total 220.00 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 220.00 0.00 0.00 0.00 0.00 Thomas J. laegnanl D.D.S. AMn Grayson D.O.S. 7 West 5151 Street 7th Floor New York NY 10019 (212) 686-1090 EFTA01122953  STATEMENT Thomas J. Magnani D.D.S. Telephone: (212) 688-1090 Alvin Grayson D.D.S. 7 West 51st Street I Wog by cryailast. OM. MO anoint yen are poling FM teyeaance box aloof bekw. 7th Floor Witilawd May New York NY 10019 Cud • Exp Stenin Dada Jeff Epstein Date Account 9 East 71st Street 6/3/2015 3114 New York NY 10021 Remilanca SIPORTANT • PUG= DETACH UPPER PORTIONNCRIMJRN NTHMIR REACTANCE TO INSURE CREPT TO PROPER ACCEMMT Date Patient Description Charges Credits Balance 4/30/2015 Previous Balance 0.00 5/19/2015 Jeff Recall Oral Exam 40.00 40.00 5/19/2015 Jeff Adult Scale & Prophy 180.00 220.00 3 poc_96-.___ , ficyv Account Total 220.00 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 220.00 0.00 0.00 0.00 0.00 Thomas J. Magnani D.D.S. Akin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 (212)688.1090 EFTA01122954  STATEMENT Thomas J. Magnani D.D.S. Telephone: (212) 688-1090 Alvin Grayson D.D.S. 7 West 61st Street ■Ooy'N by ma cat. MW INT Emma ma as WOW MM n,Ms,c.Doi EEE awl Wow. 7th Floor Malward NY Mw New York NY 10019 Cad Ea OW awakes St Cosi Jeff Epstein Date Account 9 East 71st Street 9/30/2015 3114 New York NY 10021 Remnant* WPORTMa • EtFASE OETACN UPPER PORTIONNU RETURN WIN VOLE REIETTANCE TO 1141104 CROTTY 10 PROPER a:COUNT Date Patient Description Charges Credits Balance 8/26/2015 Previous Balance 0.00 8/28/2015 Jeff Recall Oral Exam 40.00 40.00 8/28/2015 Jeff Adult Scale & Prophy 180.00 220.00 Account Total 220.00 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 220.00 0.00 0.00 0.00 0.00 Thomas J. Magner)] D.O.S. Alvin Grayson D.O.S. 7 West 51st Street 7th Fbor New York NY 10019 (212)688-1090 EFTA01122955  STATEMENT Thomas J. Magnani D.D.S. Telephone: (212) 688-1090 Alvin Grayson D.O.S. 7 West 51st Street pan by nal tent ocae Na aTa.nl man:WPM in Ra nanOnce boXrd NW Gana 7th Floor Mokami Von Amu New York NY 10019 Cad Ell DS &analuro SO Cale Jeff Epstein Date Account 9 East 71st Street 10/29/2015 3114 New York NY 10021 Remittance IMPORTANT • PLEASE DETACH UPPER POROON MO RETURN Will YOUR RFJaITANCE TO INSURE OREM TO PROPER ACCOUtff Date Patient Description Charges Credits Balance 9/30/2015 Previous Balance 220.00 9/30/2015 Jeff endosteal implant 3,000.00 3,220.00 9/30/2015 Jeff Cone beam CT image half jaw 525.00 3,745.00 10/20/2015 Jeff AMERICAN EXPRESS 220.00 3,525.00 Account Total 3,525.00 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 3,525.00 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) 688-1690 EFTA01122956  HISTORICAL STATEMENT 1/5/2016 to 2/24/2016 Thomas J. Magnani D.D.S. Telephone: (212) 688-1090 Alvin Grayson D.D.S. 7 West 61st Street 7th Floor New York NY 10019 Jeff Epstein Date Account 9 East 71st Street 2/24/2016 3114 New York NY 10021 Romeance NPORTANT PLEASE DETACH UPPER PORTION NC REM/MI/4Th YOUR RENTTAKE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/25/2015 Previous Balance 0.00 1/5/2016 Jeff Abut Sup Porc/Gold Crown 2,300.00 2,300.00 1/5/2016 Jeff Abutment Placement 1,400.00 3,700.00 2/3/2016 Jeff Adult Scale & Prophy 180.00 3,880.00 2/3/2016 Jeff Recall Oral Exam 40.00 3,920.00 2/24/2016 Jeff AMERICAN EXPRESS 3,920.00 0.00 Account Total 0.00 Patient Charges 3,920.00 Patient Payments 3,920.00- Patient Credits 0.00 Patient Debits 0.00 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 0.00 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 EFTA01122957  STATEMENT Thomas J. Magnani D.D.S. Telephone: (212) 688-1090 Alvin Grayson D.D.S. 7 West 61st Street I paying by veal cant *Met tha Mount yo., are p>/n0 U M lemlanCe 00A *?d el out beton. 7th Floor MastcaN Vloa Mut New York NY 10019 Gird • ESP Oso 5Grusliefi Sig COZO Jeff Epstein Oate Account 9 East 71st Street 3/30/2016 3114 New York NY 10021 Remit:Inca rUPORTAN1 . PLEASE DETACH UPPER PORTION N40 RLT LAIN WIN YOUR REIATTNCE TO INSURE CREDIT' TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 3/2/2016 Previous Balance 0.00 3/7/2016 Jeff Temporary Cement 375.00 375.00 3/30/2016 Jeff 1 Surface Comp. Posterior 425.00 800.00 l6 rf b 6 ,- Account Total 800.00 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 800.00 0.00 0.00 0.00 0.00 Thomas J. Magnanl D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New Voik NY 10019 (212)688-1010 EFTA01122958