HISTORICAL STATEMENT 12/1/2014 to 3/3/2015 Thomas J. Magnanl D.D.S. Telephone: Alvin Grayson D.D.S. 7 West 51 at Street 7th Floor New York NY 10019 Mr. Jeff Epstein Date Accou 9 East 71st Street 1 3/3/201 New York NY 10021 ROM ittan CO up-ORTR/7 . PLEASE CETACS 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 180.00 570.00 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 8,135.00 1/30/2015 AMERICAN EXPRESS 635.00 7,500.00 2/9/2015 1 Periapical X Ray 25.00 7,525.00 Account Total 7,526.00 Patient Charges 8,160.00 Patient Payments 636.00- Patient Credits 0.00 Patient Doblts 0.00 Wo accept credit cards! You may comply: a and return the top part of this statement, or call the office: at 212488-1090. Current 30 Days 60 Days 90 Days 26.00 7,600.00 0.00 0.00 Ti*rnae J. Mivnani 0 D.S. Alvin Grayson D.O.S 120* Days 0.00 EFTA_R1_021 34698 EFTA02713225