EFTA01919018.pdf

STATEMENT Thomas J. Magnani D.D.S. Telephone: Alvin Grayson D.D.S. L 7 West 51st Street It parn try axial cant *ow two @mum rzu in 0xr*0 ix Wolobsool box GM fa au ben 7th Floor Mastecat0 vww New York NY 10019 Cora r Exp Sprain Sp Cads • ^ Mr. Jeff Epstein newt, d iun Date Account P.O. Box 806 4/30/2014 10055 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 4/21/2014 Sue Recall Oral Exam 40.00 40.00 4/21/2014 Sue Adult Scale & Prophy 180.00 220.00 4/21/2014 Sue Bleaching Trays 650.00 870.00 4/22/2014 Sue 1 Surface Comp. Posterior 275.00 1,145.00 4/22/2014 Sue Comp. W. Etch 3 Surface 375.00 1,520.00 Account Total 1,520.00 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 I 120+ Days —h- 1,520.00 0.00 0.00 0.00 0.00 Thomas J. Magnani D.O.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 (212) 688-1090 EFTA_R1_00360643 EFTA01919018