EFTA01155767

STATEMEN Thomas J. Magnani D.D.S. Telephone: (212) 688-1090 Alvin Grayson D.D.S. 7 West 51st Street II paying by credit cant ant too amount you are ph+n; on IM rempnanco box and hi out tdow 7th Floor Masimard Visa Amens New York NY 10019 Card N Fip On &gnaw.* So Con Mr. Jeff Epstein Date Account 301 East 66th Street 12/14/2010 9648 Apt 1OF Remittance New York NY 10065 1111)-1 IC/\_ IMPORTANT. PLEASE DETACH UPPER PORTION AND RETURN WITH YOLK RES/TRANCE TO iNSVRE CREW TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/24/2010 Previous Balance 0.00 11/22/2010 FMS with Bite wings 175.00 175.00 11/22/2010 Amalgam 1 Surface Perm. 325.00 500.00 11/22/2010 Amalgam 3 Surface Perm. 375.00 875.00 12/13/2010 Comp. W. Etch 1 Surface 275.00 1,150.00 12/13/2010 Comp. W. Etch 1 Surface 275.00 1,425.00 Account Total 1,425.00 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 1,425.00 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 EFTA01155767 STATEMENT Thomas J. Magnani D.D.S. Telephone: (212) 688-1090 Alvin Grayson D.D.S. 7 West 51st Street Fr eay.-.2 by cce•VI caPd 'Mr IM amount you Tero Paling 0, tluI NnNINACCT Oao and La out !claw 7th Floor Itoolorcad VIta Amex New York NY 10019 Cord a Exp Dag Sloshes Sc Oa Mr. Jeff Epstein Date Account 457 Madison Avenue 11/24/2010 9649 4th Floor Remittance New York NY 10022 IMPORTANT • PLEASE CETACH UPPER PORTION AND RETURN WITH YOLK REMITTANCE TO INSURE CRE-DR TO PROPER ACCOUNT Date Patient Description Charges Credits Balance Previous Balance 0.00 11/24/2010 Comprehensive Oral oval 50.00 50.00 11/24/2010 Adult Scale & Prophy 160.00 210.00 Account Total 210.00 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 210.00 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 Now York NY 10019 EFTA01155768 STATEMENT Thomas J. Magnani D.D.S. Telephone: (212) 688-1090 Alvin Grayson D.D.S. 7 West 51st Street !paying by Crodol este ante, the Amount Mu are papal' Ni the renvItanCe box and NI out tekne 7th Floor Welotrellib Visa bine% New York NY 10019 card t EN, Date Sanalbre So Cod. Mr. Jeff Epstein Date Account 457 Madison Avenue 11/24/2010 3114 4th Floor Remittance New York NY 10022 IMPORTANT. PLEASE CETACH UPPER PORTION AND RETURN WITH YOUR RETATTAXCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 10/27/2010 Previous Balance 1,900.00 10/27/2010 Jeff MASTER CARD 1,900.00 0.00 10/27/2010 Jeff Ins Form submitted - Aetna 11/19/2010 Jeff Recall Oral Exam 35.00 35.00 11/19/2010 Jeff Adult Scale & Prophy 160.00 195.00 11/19/2010 Jeff Ins Form submitted - Aetna Account Total 195.00 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 195.00 0.00 0.00 0.00 0.00 Thomas J. Magnani 0.D S Alvin Grayson D.D.S 7 West 51st Street 7th Floor New York NY 10019 EFTA01155769