EFTA00749336.pdf

PPR-M-M09 10:10a Rn r FRal:D New York NY 10019 -; :rarvin i. 6/i teue Jeff Epstein St Thomas Virgin Islands 00802 Telephone: P.1 , 1 pimp by emit us* nee no Arcot ircu rts ROPRO nn nealcoOD:OR sr4 law Polaw Uniatand Peno Cal P DR We Wpm, So Coos Date 4/30/2009 Account Remittance (WORT ANT • PLEASE OETACt4 UPPER PORTION NC RETURN VAIN YOUR RENOUNCE TONSURE CREW TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 4/21/2009 50.00 50.00500°° 0 . 4/21/2009 175.00 22 4/21/2009 65.00 290.00 4/21/2009 160.00 450.00 4/21/2009 • 12.00 462.00 4/22/2009 462.00 0.00 4/29/2009 25.00 25.00 4/29/2009 425.00 450.00 4/29/2009 425.00 875.00 Account Total 875.00 Wo accept credit cards. You may complete a n the top part of this statement, or call the office at Current I 30 Dayt 60 Dayc 00 Dayc 120* Days 875.00 0.00 0.00 0.00 0.00 EFTA00749336