EFTA02724411.pdf

SEP-7-2011 11:138 FROM:DR TI-CMS MAGIANI 2123979008 T0:16467067223 P.1'1 t HISTORICAL STATEMENT 1/1/2011 to 9/7/201 Thome Magnani D.0.8. Telepho Alvin on D.D.S. stein Date Account th Street 9/7/2011 9824 Date De notion Charges Credits Balance 6/3/2011 Corr prehensive al eval 60.00 60.00 6/3/2011 Adult Scale & Pr by 180.00 240.00 6/3/2011 Pantmic Film 150.00 390.00 6/3/2011 Bite ings 4 Fil 50.00 440.00 6/6/2011 AmOgam 1 Surf Perrn, 275.00 715.00 6/6/2011 Amalgam 2 Surf Perm. 375.00 1,090.00 6/6/2011 Am4gam 2 Surf Perm, 375.00 1,465.00 6/21/2011 Amalgam 2 Surf Perm, 375.00 1,840.00 6/21/2011 Amalgam 2 Surf Perm, 375.00 2,215.00 I Account Total 2,215.00 Patient Charges 2,215.00 Patient Payments 0.00 Patient Credits 0.00 Patient Debits 0.00 Current Is 90 Days 120+ Days AN1Grayson D.D.S 7 West 51st Street New York NY 10019 (212) 688-1090 EFTA_R1_02211240 EFTA02724411