STATEMENT
Thomas J. Magnani D.D.S. Telephone
Alvin Grayson D.D.S.
7 West 51st Street payrg I y aecl4 card. lute tlM arnouni you .it plying el fa reatittince boa and
fil col Mow
7th Floor Messcate1 Vas Amex
New York NY 10019
Cues Exp Des
Donau.* Sp Cede
Mr. Jeff Epstein Date Recount
9 East 71st Street 3/28/2015 10918
New York NY 10021 Remittance
NOORTANT • PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMMNCE TO INSURE CREW TO PROPER ACCOUNT
Date Patient Description Charges Credits Balance
2/26/2015 Previous Balance 0.00
2/26/2015 Simon Comprehensive Oral eval 60.00 60.00
2/26/2015 Simon Adult Scale & Prophy 180.00 240.00
2/26/2015 Simon Fluorid 12.00 252.00
2/26/2015 Simon FMS with Bite wings 175.00 427.00
3/2/2015 Simon Adult Scale & Prophy 180.00 607.00
3/5/2015 Simon Amalgam 2 Surface Perm. 450.00 1,057.00
3/5/2015 Simon Amalgam 3 Surface Perm. 475.00 1,532.00
3/5/2015 Simon Amalgam 2 Surface Perm. 450.00 1,982.00
3/9/2015 Simon Amalgam 2 Surface Perm. 425.00 2,407.00
3/9/2015 Simon Amalgam 2 Surface Perm. 425.00 2,832.00
3/17/2015 Simon Amalgam 2 Surface Perm. 475.00 3,307.00
3/17/2015 Simon Amalgam 3 Surface Perm. 475.00 3,782.00
3/19/2015 Simon Amalgam 2 Surface Perm. 425.00 4,207.00
Account Total 4,207.00
if payment has been sent, please disregard this statement - Thank You.
We accept credit cards! You may complete and return the to part of
this statement, or call the office at
Current 30 Days 60 Days 90 Days 120+ Days
4,207.00 0.00 0.00 0.00 0.00
Thomas J. Magnani AMn Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019
EFTA00670850