STATEMENT Thomas J. Magnani D.D.S. Telephone Alvin Gra son D.D.S. II eau re by ciali card. enter Oa Oladig you ern parcel er The malacca boa end III out War Meslercerd Vna Atilln Card • Esp Wee Sidman Sy Cale Mr. Jeff Epstein 9 East 71st Street New York NY 10021 Date Account 7/29/2015 10345 Remittance IMPORTANT PLEASE DETACH TAPER PORTION ANO RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT • Date Patient Description Charges Credits Balance 7/1/2015 7/9/2015 7/9/2015 7/9/2015 Previous Balance - ecall Oral Exam Adult Scale & Prophy Orthodontic retainer 40.00 180.00 1,500.00 0.00 40.00 220.00 1,720.00 Account Total 1,720.00 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 1,720.00 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 New York NY 10019 (212) 688-1090 EFTA_R1_02129357 EFTA02712230