EFTA00311292.pdf

STATEMENT Thomas J. Magnani D.D.S. Telephone: Alvin Grayson D.D.S. 7 West 51st Street rt prwrp by credriald. onler the coon you we miner UM tiordlince b snit fill 04.4 belOvi 7th Floor Malietaird VIM /hex New York NY 10019 Cad Oeis Silenalum Sp Cos Dab Jeff Epstein P.O. Box 806 add/WI-1 4/30/2014 Account New York NY 10150 Remittance IMPORTANT • PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 3/27/2014 Previous Balance 0.00 4/23/2014 Jeff 1 Periapical X Ray 25.00 25.00 4/25/2014 Jeff surgical extraction 1,200.00 1,225.00 4/25/2014 Jeff Gum Graft 1,200.00 2,425.00 4/29/2014 180.00 2,605.00 40.00 2,645.00 4/29/2014 4/29/2014■ 175.00 2,820.00 Account Total 2,820.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cardsl You may complete and return the top part of this statement, or call the office a . Current 30 Days 60 Days 90 Days 120+ Days 2,820.00 0.00 1 0.00 0.00 0.00 Thomas J. Magnani D.D.S. Alen Grayson O.D.S. 7 West Stet Street 7th Flow New York NY 10019 EFTA00311292