EFTA00621611.pdf

APR-13-2011 10:29A FROM:DR THOMAS HAGMANI 2123979008 TO:16467067223 P.1/1 Thom . Alvin 7W 71h Fl New Mr. 301 EA Apt 10 Now HISTORICAL STATEMENT 11/22/2010 to 4/13/2011 it Telephone: (212) 688-1090 Date Account 4/13/2011 9648 Date De ription Charges Credits Balance 11/22/2010 FM with Bite wi s j I 175.00 175.00 11/22/2010 Am. gam 1 Surf Perm, 325.00 500.00 11/22/2010 Atom 3 Surf Perm, t j S 375.00 875.00 12/13/2010 Co p. W. Etch 1 urface p 275.00 1,150.00 12/13/2010 Corhip. W. Etch 1a urface j 275.00 1,425.00 12/14/2010 Co prehensive al eval i 50.00 1,475.00 12/14/2010 Adu . Scale & Pr. hy : 160.00 1,635.00 12/17/2010 MA ER CARD i 1,425.00 210.00 12/20/2010 Por lain W. Gol Crown i k 1,850.00 2,060.00 1/7/2011 Ep teal Implant i i i 2,300.00 4,360.00 117/2011: Ep teal Implant i 2,300.00 6,660.00 1/14/2011 Off Visit 0.00 6,660.00 1/21/2011 MA TER CARD 1,850.00 4,810.00 1/25/2011 Pordelain W. Gol rown 4 1,850.00 6,660.00 2/10/2011 1 P 'apical X R ! ' 25.00 6,685.00 3/2/2011 r Am ,gam 2 Surf: Perm, 375.00 7,060.00 , i I Account Total 7,060.00 I I i f. i Patient Charges 10,336.00 Patient Payments 3,275.00- i i Patient Credits 0.00 Patient Debits 0.00 Cu ent 30 Days 60 pays 90 Days 120+ Days i i as J. Mr gnanl Alvin Grays D D.S. nAlest 514 Stitt ri I Ji Floor New York NY 10019 EFTA00621611