EFTA00599985.pdf

STATEMENT Thomas J. Magnani D.D.S. Telephone: Alvin Grayson D.D.S. I paying by credit cant enter Me amount you are barna in IM rempitance box and hi out below Masten:ant visa Amax Card N Gip Des Soanatunt So Cods Mr. Jeff Epstein Date Account 301 East 66th Street 12/14/2010 9648 Apt 1OF Remittance New York NY 10; rn kf PAPORTANT PLEASE DETACH UPPER PORTION AND RETURN WITH YOLK REIETTANCE TO INSURE CREDIT 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 Account Total 1,425.00 We accept credit cards! You may complete and return the top part of this statement, or call the office at 212488-1090. Current 30 Days 60 Days 90 Days 120+ Days 1,425.00 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 Now York NY 10019 EFTA00599985  STATEMENT Thomas J. Magnani D.D.S. Telephone: Alvin Grayson D.D.S. " PaY., 3 t cteltl crd enter Ow amovg you w paling in an re'n.r2^c," cov end Ls out !claw Amex Cord 0 Up Dail Sloshes Sc Don Mr. Jeff Epstein Date Account 457 Madison Avenue 11/24/2010 9649 4th Floor Remittance New York NY 10022 IMPORTAIC • PLEASE DETACH UPPER PORTION AND RETURN WITH YOLK REmITTANDE TO INSURE CRC -DR TO PROPER ACCOLAIT Date Patient Description Charges Credits Balance Previous Balance 0.00 11/24/2010 Comprehensive Oral oval 50.00 50.00 11/24/2010 Adult Scale & Prophy 160.00 210.00 Account Total 210.00 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 210.00 0.00 0.00 0.00 0.00 Thomas J. Maona ro D.D S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor Now York NY 10019 EFTA00599986  STATEMENT Thomas J. Magnani D.D.S. Telephone: Alvin Grayson D.D.S. 7 West 51st Street r pay% by Clodol Cu. antes the amount yOu are payong n PH reinba 0 Wu and Id out Wow 7th Floor Mastrusal Vni Amax New York NY 10019 Caro . EN, Oar Srature SO Cato Mr. Jeff Epstein Date Account 457 Madison Avenue 11/24/2010 3114 4th Floor Remittance New York NY 10022 IMPORTANT. PLEASE CETACH UPPER PORTION AND RETURN WITH YOUR REfrATTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 10/27/2010 Previous Balance 1,900.00 10/27/2010 Jeff MASTER CARD 1,900.00 0.00 10/27/2010 Jeff Ins Form submitted - Aetna 11/19/2010 Jeff Recall Oral Exam 35.00 35.00 11/19/2010 Jeff Adult Scale & Prophy 160.00 195.00 11/19/2010 Jeff Ins Form submitted - Aetna Account Total 195.00 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 195.00 0.00 0.00 0.00 0.00 Thomas J. Magnani 0.D S Alvin Grayson D.D.S 7 West 51st Street 7th Floor New York NY 10019 EFTA00599987