EFTA00619776.pdf

2123979008 TO:16.467067223 r• l'1 MAR-22-2002 09:58 FROM:OR.MAGNANI Thomas J. Magnani D.D. Mr. Jeff Epstein 301 East 66th Street Apt 1OF New York NY 10066 HISTORICAL STATEMENT 1/1/2013 to 3/21/2013 Telephone Dole Account 3/21/2013 9648 Date Patient '1' Description Charges Credits Balance 1/4/2013 1/4/2013 1/4/2013 1/9/2013 1/29/2013 1/30/2013 Recall Adult 50ale Add Per Amalgti Porcelall Case et 4 ral Exam & Prophy apical X Rays 2 Surface Perm. W. Gold Crown mplete i t 40.00 180.00 10.00 375.00 900.00 0.00 40.00 220.00 230.00 605.00 1,505.00 1,505.00 T. 'I s .:i i. 1 t N i r 5 Account Total 1,605.00 ., i Patient Charges 1,506.00 Patient Payments 0.00 2; I Patient Credits 0.00 s Patient Debits 0.00 Current 30 Days 60 Days 90 Days 120+ Days Thomas J. Megnani D.D.S AMn G D.D.S. 7 West Slat Strom 7ttbor New York NY 10019 (212) 688-1090 EFTA00619776