• . *AS grAitk CHART NO. PAGE NO. Thomas J. MagnanL D.D.S. 7W51 DENTAL GROUP 1 614/111ONTDI! :; DUE DATE 7 W 51st Street. Floor 7 Nsia11.19 (16/14/2017 07/14/2017 CREDIT CARD a EXP NAME GUARANTOR NAMEAND MAILING ADDRESS As i emeareenconli Mr Jeff Epstein 9 East 71st Street SIGNATURE New York, NY 10021 TYPE OF CARD laP tatifftac LCISED SECURITY CODE TO:ENSURE PROPER CREDIT,: iimatvo.ftwootioriiiib6404.10034si PLEASE RETAIN SKS PORTION OF DIE STATEMENT FOR YOUR RECORDS -11,710' WPOW //ga r CREDITS 05/01/2017 Balance Fonvard 0.00 05/18/2017 Prophylaxis-adult Jeff 180.00 05/18/2017 Periork oral evaluation Jeff 40 00 F-..a/RIENT,BA10400. :::?,:WERi.(SAYD -li GO &ORS : :.'0W 14-11420/01. ,; ' 'it iikitige l i CE 220.00 0.00 0.00 0.00 220.00 Make charts payable to: Thomas J. Magnin. DDS. To pay by Credit Card, please cal our office at PLEASE PAY ina, THIS AMOUNT nr 220.00 01987-2012 Henry Schein, Inc. Thomaill'Unrani. D D S - 7W51 DENTAL GROUP 7 W Slst Street, Floor 7 New York. NY 10019 EFTA00316345