STATEMENT
Thomas J. Ma . Telephone:
Alvin Grayson
IM MO bY COON cad. Oftlit the Sniourd you we ming n Ire in CS OCCC ells
Out below
Mastercard Asa Amex
Card• E,p OM.
WAIN Sig COOS
/Mr. Jeff Epstein Date Account
/ 301 East 66th Street 5/9/2013 9293
I Apt 3 1OF Remittance
' New York NY 10065
impoR, ;4,4 MINN OfThtli UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT
77:late Patient Description Charges Credits Balance
3/28/2013 Previous Balance 0.00
4/2/2013 Svetleana Recall Oral Exam 40.00 40.00
4/2/2013 Svetleana Adult Scale & Prophy 180.00 220.00
4/2/2013 Svetleana Bleach Touch-Up Kit 65.00 285.00
Account Total 285.00
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
Current 30 Days 60 Days 90 Days 120+ Days
285.00 0.00 0.00 0.00 0.00
Thomas J. Magnani Alvin Grayson M.
EFTA00313134