EFTA00622144.pdf

STATEMENT Date Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Mr. Jeff Epstein 301 East 66th Street Apt 10F New York NY 10065 Telephone: (212) 688-1090 Parn0 by Neat ewe Genet Ono amount you we porn on the recartlance bax and kJ out below lolantemard _ Vaa Amex Ciinf Sognatunio iv Dale S9 Cede Date Account 1/5/2011 Remittance IMPORTANT • PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO RISME CREDIT TO PROPER ACCOUNT 11/24/2010 11/22/2010 11/22/2010 11/22/2010 12/13/2010 12/13/2010 12/14/2010 12/14/2010 12/17/2010 @M0/2010' Patient Description Charges Credits Balance Previous Balance 0.00 FMS with Bite wings 175.00 175.00 Amalgam 1 Surface Perm. 325.00 500.00 Amalgam 3 Surface Perm. 375.00 875.00 Comp. W. Etch 1 Surface 275.00 1,150.00 Comp. W. Etch 1 Surface 275.00 1,425.00 Comprehensive Oral eval 50.00 1,475.00 Adult Scale & Prophy 160.00 1,635.00 MASTER CARD 1,425.00 210.00 Porcelain W. Gold Crown 850.00 2,060.00 Account Total 2,060.00 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 2,060.00 0.00 0.00 0.00 120+ Days 0.00 Thomas J. Mooning D. D S. Alvin Grayson D O.S 7 West 51st Street 7th Floor Now York NY 10019 EFTA00622144