EFTA00313687.pdf

STATEMENT OF ACCOUNT 7W51 DENTAL GROUP 7 W 51st Street Floor 7 New York, NY 10019 GUARANTOR NAME AND MAILING ADDRESS Ms 1D02" CHART NO. I PAGE NO. 1 BILLING DATE D2/7(222'1 AMOUNT ENCLOSED I TO ENSURE PROPER CREDIT. PLEASE DETACH AND RETURN THIS PORTION OF THE STATEMENT WITH YOUR PAYMENT DATE raw TlirSPORTIONOg DESCRIPTION W . PATIENTS NAME CHARGES CREDITS 01/01/2017 Balance Forward 220.00 01/12/2017 Pre-Conversion Person Payment -223 00 01/19/2017 Drugs/medicaments for home use 24.00 CURRENT BALANCE OVER 30 DAYS OVER 60 DAYS OVER 90 DAYS TOTAL BALANCE 24.00 0.00 0 00 C 00 24.00 For your convenience. we offer the option of payment by Visa and Maste'Card Wnen paying by credit card please fill out the credit card information in the remittance portion above (.5.: 1987-2012 Henry Schein. Inc. 7W51 DENTAL GROUP - 7 W 51st Street Floor 7 New York. NY 10019 (212)688-1090 EFTA00313687