Epstein Secrets

UPPER PORT )N MD RETURN WiTI- YOUR io MITTA *CC TO u. UAL CRC CO TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 6/20/2014 Previous Balance 0.00 12/17/2014 Amalgam 2 Surface Perm. 350.00 350.00 12/17/2014 Recall Oral Exam 40.00 390.00 12/17/2014 Adult Scale & Prophy 180.00 57

nce 6/20/2014 Previous Balance 0.00 12/17/2014 Amalgam 2 Surface Perm. 350.00 350.00 12/17/2014 Recall Oral Exam 40.00 390.00 12/17/2014 Adult Scale & Prophy 180.00 570.00 12/17/2014 Bite Wings 4 Films 65.00 635.00 1/8/2015 Panoramic Film 0,00 635.00 1/8/2015 Ortho treatment adult 7,500.00 8,

ACH UPPER PORTION MO RETURN 'MTH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 6/3/2015 Previous Balance 0.00 6/16/2015 Adult Scale & Prophy 180.00 180.00 6/16/2015 Recall Oral Exam 40.00 220.00 6/16/2015 Electric toothbrush 160.00 380.00 6

UR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 6/3/2015 Previous Balance 0.00 6/16/2015 Adult Scale & Prophy 180.00 180.00 6/16/2015 Recall Oral Exam 40.00 220.00 6/16/2015 Electric toothbrush 160.00 380.00 6/16/2015 Laser Bleaching 750.00 1,13

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

COLAIT 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 21